COUNSELING FORM Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY What type of counseling are you looking to receive? * Individual Counseling Marriage Counseling Family Counseling Pre-Marital Counseling Education * last year completed and/or degree earned Employer and Occupation * Marital Status * Single Dating (In a Relationship) Engaged Married Separated Divorced Remarried Widowed How long have you been in your current status? * Name of significant other? * Occupation of significant other? * Does your significant other know you are looking to receive counseling? * yes no How long did you date your significant other and/or how long have you been married? * If married, have you ever been separated from your current spouse? If yes, for how long and what was the reason for the separation? * If married, have you ever filed for divorce from your current spouse? * Have you been previously married? If yes, give a brief explanation of the relationship. * List any children. Ages, gender, biological, step, adopted? * Are your parents living? If yes, where do they live? * Describe your relationship with your father. * Describe your relationship with your mother. * How many siblings do you have? Where are you in the birth order? * Have you ever had counseling before? * yes no If yes, for how long, what for, and what was the outcome of the counseling? * Have you ever been arrested? * yes no If yes, give a brief explanation. * List any fears you have. * Have you ever had severe emotional upset? If yes, explain. * What was your spiritual/religious background in your childhood? * Would you say that you are a Christian or are you in the process of becoming a Christian? * In your own words, what does it mean to be a Christian? * What church do you presently attend? * Are you a member of that church? * yes no What is your church's denomination? * How often do you attend church per month? * How are you involved within your church? * May we contact your pastor for background information? * yes no If yes, please include your pastor's name, email and phone contact: * If no, please explain why not: * How often do you read the Bible? * How often do you pray to God? * Have you been water baptized? If yes, when? * How would you describe your spiritual life? * Rate your overall health: * Very good Good Average Declining Poor Do you CURRENTLY have any health issues or any chronic conditions? If yes, please describe: * List any other important/significant illnesses or injuries: * Approximately how many hours of sleep do you get each night? * Briefly describe the quality of your sleep? * Have you ever been diagnosed with a mental health issue? If yes, please describe: * Are you presently taking any medication? If yes, what is it and what are you taking it for? * Do you drink alcoholic beverages? If yes, how frequently and how much? * Have you or others noticed any recent changes in your personality (anger, mood swings, withdrawal, etc.), thinking, memory, or work habits? If yes, briefly explain: * Mark the following words that best describe you: * Active Hardworking Excitable Shy Leader Lonely Ambitious Impatient Imaginative Fearful Quiet Self-concious Self-confident Impulsive Calm Introvert Extrovert Inflexible Bitter Persistent Moody Serious Submissive Angry Anxious Often sad Easy going Likeable Headstrong What are the issues you are struggling with (what brings you here)? * Please give a general explanation concerning why you are seeking biblical counseling. What personal steps have you taken to resolve the issue(s)? * What are your expectations in seeking biblical counseling with us? * Is there any other information we should know? * You were referred to us by: * Do you prefer: * In person Sessions Online Sessions Both (Sometimes online, but open to meeting in person as well.) Do you have a preferred counselor? If so, list the name below: * If you are requesting couples counseling, each party must complete the counseling form. * I agree to having my significant other also complete a counseling form. not applicable By submitting the counseling form, I agree to being contacted by Arise Biblical Counseling. Once I am assigned a counselor, I agree to having a credit card on file and to be charged for each session after the session is completed. Otherwise I agree to pay for each session within 24 hours after the session is completed. * Thank you for submitting the counseling form. We will be in touch with you soon with next steps.