Application for Counseling

Identification Data

Name:(Required)

First Last

Phone:(Required)

Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code

Email:(Required)

Occupation:(Required)

Work Phone:(Required)

Birth Date:(Required)

Age:(Required)

Sex:(Required)

Male

Female

Marital Status:(Required)

Single

Engaged

Married

Separated

Divorced

Remarried

Widow

Education:(Required)

Elementary

High School

GED

College

Graduate

Degree / Certificate

Other Training (Type & Years):(Required)

Hobbies:(Required)

Referred to us by:(Required)

Relationship:(Required)

If you were raised by anyone other than your own parents, breifly explain:(Required)

How many older brothers do you have?(Required)

How many older sisters do you have?(Required)

How many younger brothers do you have?(Required)

How many younger sisters do you have?(Required)

Marriage Information:

Name of Spouse:

First Last

Address:

Street Address City State / Province / Region ZIP / Postal Code

Occupation:

Phone:

Age:

Work Number:

Religion:

Education:

Does your spouse know you are coming for counseling?

Yes

Is your spouse willing to come to counseling?

Yes

Uncertain

Have you ever been separated?

Yes

When?

From: Till:

Your ages when married?

Husband: Wife:

Wedding Date:

How Long did you know your spouse before marriage?

Length of steady dating with spouse:

Length of Engagement

Give brief information about any previous marriages:

Information about Children:

Please provide the following information about all your children. If a child is from a previous marriage put PM before their entry. (PM?) Name - Birthdate - Sex - Living? -Education (Yes/No) Marital Status

Health Information

Have you ever had a sever emotional upset?(Required)

Yes

Have you ever had any psychotherapy or counseling before?(Required)

Yes

If yes, list counselor or therapist and dates:

What as the outcome?

Check off any of the following words which best describe you now:(Required)

Mark if at any time you have:

Felt people were watching you?

Had difficulty recognizing faces?

Been unable to judge distance?

Had visual hallucinations?

Had auditory (hearing) hallucinations?

List fears you have:(Required)

Have you been arrested?(Required)

Yes

Reason

Approximately how many hours of sleep do you get each night?(Required)

When do you go to sleep at night?(Required)

When do you get up?(Required)

Rate your health:(Required)

If other explain:

Approximate Weight:(Required)

Approximate Height (Feet & Inches):(Required)

Recent weight changes, gained or lost:(Required)

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?(Required)

Name of Physician:(Required)

First Last

Address of Office

Street Address City State ZIP Code

Are you presently taking medication?(Required)

Yes

What(Required)

Have you used drugs for other than medical purposes?(Required)

Yes

What(Required)

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?(Required)

Yes

Religious Background

Denominational preference:(Required)

What church do you attend?(Required)

City(Required)

Who is your pastor?(Required)

May we contact your pastor for background information?(Required)

Yes

What is the number of church services you attend per month?(Required)

Church attended in childhood:(Required)

Do you believe in God?(Required)

Yes

Uncertain

Do you pray to God?(Required)

Yes

Occasionally

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?(Required)

Yes

Uncertain

Religious background of spouse:(Required)

Suppose you died today and God asked you "Why should I let you into my heaven?" What would you say?

Are you saved?(Required)

Yes

Uncertain

How much do you read the Bible?(Required)

Often

Never

Occasionally

Does your family regularly read the Bible together?(Required)

Yes

Does your family regularly pray together?(Required)

Yes

Does your family regularly attend worship together?(Required)

Yes

Explain any recent changes in your religious life, if any?

Five Basic Questions

Briefly answer the following questions:

1. What are the issues you are stuggling with?(Required)

2. What have you done about it?(Required)

3. What do you want us to do? (What are your expectations in coming here?)(Required)

4. What brings you here at this time?(Required)

5. Is there any other information we should know?(Required)

On rare occasions a conflict may develop between a counselor and counselee. In order to make sure that such conflicts will be resolved in a biblically faithful manner, we require all of our counselees to agree that any dispute that arises with a counselor or with BCM as a result of counseling, will be settled by mediation and if necessary, legally binding arbitration in accordance with the Rules or Procedure of the Institute for Christian Conciliation; judgment upon arbitration award may be entered in any court having jurisdiction.

Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about these guidelines, please talk with the administrator. If these guidelines are acceptable to you, please digitally sign below.

Full Name(Required)

Date

This field is for validation purposes and should be left unchanged.