Counseling Intake Form

Welcome to the counseling ministry at Bethlehem Church. We know it's not easy to ask for help and we are so grateful that you have invited us into your life at this time. It is our prayer that God will bless you and use our time together to build more hope and direction into your life. As we walk with you through this process, please complete this intake form. This will allow us to get to know you better and help you determine clear strategies and objectives. Rest assured that all of the information in this form will remain confidential.

Your name *

Last name

Email address *

Birthdate *

Phone number *

Phone type

Gender *

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Are you requesting individual counseling or marriage counseling? *

If you select Individual Counseling for a minor, please have minor fill out the form themselves.

If you select Marriage Counseling, please have your spouse fill out a separate form as well. The pastor has the right to cancel the appointment if both individuals do not complete the intake form before the date of the appointment.

Marital status *

Household members

Please add every individual living in your household.

Have you been married previously? *

Any deaths or losses in the family in the last 5 years? *

Give a brief description of any significant events, trauma, or abuse we should discuss from your childhood. (Put N/A if not applicable to you.) *

Do you consider yourself a Christian? *

Do you pray to God? *

Do you read the Bible? *

What is your relationship with Bethlehem Church? *

Have you used illegal drugs within the last 30 days? *

How many times per month do you attend Bethlehem Church? *

Rate your overall health. *

Poor

Fair

Good

Excellent

Please list any significant illnesses, injuries, or disabilities. (Put N/A if not applicable to you.) *

Please list any medication(s) you are presently taking. (Put none if not applicable to you.) *

Have you had any professional counseling before? If so, please give a short explanation. *

Do you currently consume alcohol? *

Check any of the following words that describe you. *

Active

Ambitious

Anxious

Guilty

Self-Confident

Depressed

Shy

Persistant

Nervous

Hardworking

Impatient

Impulsive

Moody

Calm

Often-Blue

Excitable

Imaginative

Serious

Easy-Going

Good-Natured

Intovert

Extrovert

Like-able

Leader

Quiet

Submissive

Self-Conscious

Lonely

List your greatest strengths. *

List your greatest weaknesses. *

Give a brief description of the challenges and struggles you are currently facing. *

What would you say is your greatest problem at this time? *

How long have you been responding to this problem? *

Describe any person(s), situation(s), or activities that seem to trigger this problem or make it worse. *

How can we help? *

What, if anything, do you fear? *

Is there any other information we should know? *

Consent to Biblical Counseling *

Our goal in providing Biblical counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to enjoy fully His love for you and His plans for your life. We are not licensed professional counselors, but our counseling is based on scriptural principles rather than secular psychology or psychiatry. Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us.

AS YOUR BIBLICAL COUNSELOR WE COMMIT TO THE FOLLOWING: Praying for and with you in our meetings. Hearing your story and understanding your situation to the best of our ability before giving counsel. Opening God's Word with you in relevant and persuasive ways. Speaking the truth in love as we address your problems. Giving homework that is helpful in your life and situation.

AS THE COUNSELEE WE ASK YOU TO COMMIT TO THE FOLLOWING: Arrive to appointments on time and remain consistent in your counseling attendance. Attend Sunday morning worship at Bethlehem Church. Spend time in prayer and Bible reading throughout each week.

I understand that checking this box constitutes a legal signature confirming that I consent to the above guidelines and confidentiality statement.

If you consent to the above guidelines and confidentiality statement, please type your first and last name below. *

By signing this I acknowledge that I've read, fully understand and agree to all information contained here.

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Bethlehem Church
info@bethlehemchurch.us
770-867-3577