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