Trinity Baptist Church of Indianapolis Counseling Ministry Intake Form
Please answer to the best of your ability. Any question you feel uncomfortable answering, you can leave blank and discuss with your counselor. Your responses are confidential.
Personal Information
Name *
Phone *
Email Address *
Address
City
State
Zip code
Gender *
Age
Occupation
Marital Status *
If you were raised by anyone other than your own parents, briefly explain:
How many siblings do you have?
1
2
3
4
5
Older Brothers
Older Sisters
Younger Brothers
Younger Sisters
Clear selection
Marriage Information
Name of Spouse/Prospective Spouse *
Phone
Age
Religion
Does your spouse know you are coming for counseling?
Clear selection
Is your spouse willing to come to counseling?
Clear selection
Have you ever been separated?
Clear selection
If so, please share when?
Marriage Date
MM
/
DD
/
YYYY
Both of your ages when married:
How long did you know your spouse before marriage?
Length of dating before marriage?
Give brief information about any previous marriages:
Children Information
Child Name #1
Please check all that apply related to the above child.
Child Name #2
Please check all that apply related to the above child.
Child Name #3
Please check all that apply related to the above child.
Child Name #4
Please check all that apply related to the above child.
Child Name #5
Please check all that apply related to the above child.
Other Children
Counseling and Medical History
Have you dealt with severe emotional struggles in your past?
Clear selection
Have you ever had any therapy or counseling before?
Clear selection
Please list counselor or therapist and dates:
What was the result of your counseling?
Have you ever been arrested?
Clear selection
Please share why and what was the result.
Do you have any chronic medical conditions? –List and Describe below:
If taking any prescribed medications, please list.
How much alcohol do you consume?
In the past five years, have you used illegal or excessive prescription drugs?
Clear selection
Religious Information
What church do you attend?
Do you desire for us to contact your pastor for background information?
Clear selection
Do you pray to God?
Clear selection
Are you a Christian?
Clear selection
Have you come to the place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?
Clear selection
How often do you read the Bible?
Clear selection
Does your family regularly read the Bible and pray together?
Clear selection
Explain any recent changes in your religious/spiritual life, if any:
Counseling Background
Briefly answer the following questions that help us understand your situation better. These questions are required. Please try your best to answer these questions.
How do you describe the issues with which you are struggling? *
What have you tried to do about it? *
How do you hope counseling might help? (What are your expectations in coming here?) *
What brings you here at this time? (Did any recent event cause you to schedule the appointment now?) *
Is there any other information you think we should know to help you? *
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