Rev. 8/8/16
Biblical Counseling Services
Personal Information Form
Please complete this form carefully and thoroughly. Return upon completion. By email:
[email protected] | By postal mail: P.O. Box 1506 Yorktown, VA 23692
PERSONAL IDENTIFICATION Name _____________________________________________________
Birth Date________________
Address _________________________________________________________
Zip _______________
Age _____ Sex _____ Referred by _____________________________ Email _______________________ Marital Status: Single ____ Engaged ____ Married ____ Separated ____ Divorced ____ Widow ___ Home Phone _______________________ Cell ____________________ Other ____________________ Occupation ________________________ Employer ____________________________ Years ______ Education (last yr. completed) ___________________ Where __________________________________ MARRIAGE & FAMILY Spouse __________________________ Birth Date ______________ Home Phone ________________ Occupation __________________________ Years Employed _______ Business Phone ________________ Date of Marriage _____________________ Length of Dating __________________________________ Give a brief statement of circumstances of meeting and dating __________________________________ _____________________________________________________________________________________ Have either of you been previously married? _________ Who? __________________________________ Have you ever been separated? ________ When? __________________ Ever filed for divorce? ________ 1
Rev. 8/8/16
Children: Name
Age
Sex
Living Y/N
Step-‐‑child Y/N
Describe your relationship with your father ________________________________________________________________ __________________________________________________________________________________________________________________ Describe your relationship with your mother ______________________________________________________________ __________________________________________________________________________________________________________________ Number of siblings _______ Your sibling order _____________________________________________ Did you live with anyone other than parents? ________________________________________________ Are your parents living? ______ Do they live locally? ________________________________________ HEALTH Describe your general health _________________________________________________________________________________ Do you have any chronic conditions? ______ What? ________________________________________________________ List important illnesses and injuries or handicaps _________________________________________________________ __________________________________________________________________________________________________________________ Date of last medical exam ______________ Report _____________________________________________________________ Physician’s name and address _______________________________________________________________________________ Current medication(s) and dosage ___________________________________________________________________________ __________________________________________________________________________________________________________________ Have you ever used drugs for other than medical purposes? ________ If yes, please explain __________________________________________________________________________________________ Have you ever been arrested? _______ Reason ____________________________________________ Do you drink alcoholic beverages? _______ If so, how frequently and how much? _______________________ 2
Rev. 8/8/16
Do you drink coffee? _______ Other caffeine drinks? ________ How much? _________________________________ Do you smoke? ________ If so, what? _________________________ If so, how frequent? _____________________ Have you ever had interpersonal problems on the job? ________ If yes, explain _________________________ __________________________________________________________________________________________________________________ Have you ever had a severe emotional upset? _______ If yes, explain _____________________________________ __________________________________________________________________________________________________________________ Have you ever seen a psychiatrist or counselor? _______ If yes, explain __________________________________ __________________________________________________________________________________________________________________ Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records? __________ SPIRITUAL Do you believe in God? _______ Do you pray? ________ Would you say you are a Christian? ____________ Or, still in the process of becoming a Christian? ____________________________________________________________ Denominational preference __________________________________________________________________________________ Church attending __________________________________________________________________________ Member? _______ Church attendance per month (circle) 0 1 2 3 4 5 6 7 8+ Have you been baptized _________ If yes, how old were you? _______ How often do you read the Bible: Never ______ Occasionally ______ Often ______ Daily ______ Explain any significant changes in your religious life ______________________________________________________ __________________________________________________________________________________________________________________ WOMEN ONLY Is your husband willing to come for counseling? ________ Is he in favor of your coming? ________ If no, explain _______________________________________________________ __________________________________________________________________________________________________________________ 3
Rev. 8/8/16
PROBLEM CHECK LIST: _____ Anger _____ Depression _____ Anxiety (worry) _____ Drunkenness _____ Apathy (don’t care) _____ Envy _____ Appetite _____ Fear _____ Bitterness _____ Finances _____ Change in lifestyle _____ Gluttony _____ Children _____ Guilt _____ Communication _____ Health _____ Conflict (fights) _____ Homosexuality _____ Deception _____ Impotence _____ Decision-‐‑making _____ In-‐‑laws PLEASE ANSWER THE FOLLOWING QUESTIONS: 1. What is your problem (what brings you here)? 2. What have you done about this problem? 3. What are your expectations from counseling? 4. Is there any other information we should know about?
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______ Loneliness
______ Lust
______ Memory
______ Moodiness
______ Perfectionism
______ Rebellion
______ Sex
______ Sleep
______ Wife Abuse
______ A Vice
______ Other
Rev. 8/8/16
Statement of Understanding 1. I understand that the staff and biblical counselors of the biblical counseling ministry of Coastal Community Church and those associated with them are not state-‐‑licensed counselors, therapists, medical, or psychological practitioners.
2. I further understand that everything I state during these biblical counseling sessions will be kept in confidence with the exception of the two issues listed below and that I alone hold the right to release any information that comes from these sessions.
3. I understand that biblical counseling is not to be thought of as a confidential confession whereby I can confess illegal activity. I understand that the biblical counseling team members are not ecclesiastical priests and are bound by law to report illegal activity on my part. I understand that if I am breaking the civil law I am under the authority of the state (Romans 13:1-‐‑7) and it is my Christian duty to reconcile with the state.
4. I am aware that Coastal Community Church is mandated by law to intervene if he/she suspects that a child (under the age of 18 years), or an elder (over the age of 65 years), or a vulnerable adult is currently endangered by abuse or if I am a danger to myself or others. 5. I understand that I am free to leave at any time and that I am here voluntarily and under no financial obligation (except for the cost of personality inventories which will be agreed upon by my assigned biblical counselor and myself prior to such personality inventories being administered). 6. I deem the person(s) leading these biblical counseling sessions to be disciplers in the Christian faith, who is/are helping me assume my responsibilities in finding freedom in Jesus Christ through the sufficiency of God’s Word.
________________________________________________________________ Counselee’s Signature ________________________________________________________________ Print Your Name ________________________________________________________________ Signature of Biblical Counselor
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Date _____________________
