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Email
*
Your email
Name
Your answer
Phone
Your answer
Email
Your answer
Location
Greenville Area
Washington Area
Remote (Online only)
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Occupation
Your answer
Sex
Male
Female
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Age
Your answer
Marital Status
Single
Engaged
Married
Separated
Divorced
Remarried
Widow
Education (check highest accomplished)
Elementary
High School
GED
College
Graduate
Post-graduate
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Hobbies
Your answer
Marriage Information
Name of spouse
Your answer
Occupation
Your answer
Phone
Your answer
Does your spouse know that you are coming for counseling?
Yes
No
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Is your spouse willing to come to counseling?
Yes
No
Uncertain
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Please provide brief information about any previous marriages
Your answer
Information about children: Please provide age and any other relevant information.
Your answer
History Information
If you have had counseling before, what kind of counseling was it and was the desired outcome achieved?
Your answer
Rate your overall health
Very bad
1
2
3
4
5
Very good
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Have you used drugs for other than medicinal purposes?
In my past
Currently
No
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Religious Background
What church do you attend?
Your answer
Denominational preference
Your answer
Who is your pastor?
Your answer
May we contact your pastor for background information?
yes
no
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What is the number of church services you attend per month?
1
2
3
4
5
6
7
8
9
10
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Religious background of spouse
Your answer
Do you believe in God?
yes
no
uncertain
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Do you pray to God?
yes
no
uncertain
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Have you come to a 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?
yes
no
uncertain
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Suppose you died today and God asked you "Why should I let you into my heaven?" What would you say?
Your answer
How much time do you spend reading the Bible each week?
Your answer
Does your family regularly read the Bible and pray together?
yes
no
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5 Basic Questions
What are the issues you are struggling with?
Your answer
What have you done about it?
Your answer
What are your expectations from counseling?
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Is there any other information we should know?
Your answer
Send me a copy of my responses.
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