Susan Phillips Biblical Counseling

PERSONAL HISTORY

Name______Phone______Date______

Address______

Occupation______Cell Phone______

Email______Gender: M___ F___ Birth Date______Age______

Marital Status: Single____ Married____ Divorced____ Widowed____ Date of marriage______

Education: List last grade or year completed and any degrees or certificates and dates______

______

Employer______Position______How Long? ______

Referred by______

MARRIAGE AND FAMILY

Name of Spouse______Email______

Phone______CellPhone______Age______

Education completed______

Occupation and Employer______

Willing to come for counseling?______Have you been separated or filed for divorce?______

Age at marriage: Husband_____ Wife_____ How long did you know each other before marriage? ______

Previous marriages? When and for how long?______

______

Children:

NameAgeGenderYear in SchoolStepchild?

______

______

______

______

On a scale from 1 to 10, how would you rate your marriage? ______

Please check any of the following problems you are having in your marriage. Circle the 3 which are the highest priority:

___ Not resolving conflicts___ Lack of communication___ Struggling in your Christian Walk

___ Conflicts over decision-making___ Financial problems___ Selfishness

___ In-law relationships___ Unrealistic expectations___ Possessiveness/jealousy

___ Substance abuse___ Pornography___ Sexual relationship

___ Depression___ Unforgiveness___ Anger

___ Adultery___ Gambling___ Child-rearing

___ Physical abuse___ Self-destructive behavior___ Apathy

Other or additional information:______

______

Siblings’ first names and ages ______

Any deaths in the family during the last year? ______If so, who and when?______

Are your parents living? ______Still married to each other? ______Where do they live? ______

HEALTH INFORMATION

Rate your health: Very Good_____ Good_____ Average_____ Declining_____ Other______

Weight changes in past year: Lost_____ pounds or Gained _____ pounds. Is this a concern? ______

List significant present or past illnesses, injuries or disabilities: ______

______

Date of last medical examination______Outcome: ______

______

Physician name and phone______

If you are presently taking any medications/supplements or on a special diet, please describe. Include dosage for any medications along with the condition the medication is treating:

______

______

Do you drink alcoholic beverages? ______How much/How often? ______

Do you smoke? ______If so, how much/how often? ______

Do you drink caffeine? ______If so, How much/how often? ______

Have you ever used drugs other than how they were prescribed? _____ Explain: ______

Have you ever been arrested? _____ Explain: ______

Have you ever had a severe emotional upset? _____ Explain ______

______

Have you ever had any psychotherapy or counseling? _____ If so, who did you see and what was the time period?

______

Were any medications prescribed? ______List: ______

Women Only

Have you had any menstrual difficulties? ______

Do you regularly experience symptoms of PMS? _____ Describe:______

______

Have you experienced any unusual health issues related to child-bearing? ______Describe: ______

______

RELIGIOUS BACKGROUND

Current Church Attending______Pastor’s Name______

May we contact your pastor for information and help? No_____ Yes_____

I attend church for worship, bible study or ministry ______times (average) in a month.

I have been baptized _____ At what age and by whom? ______

Churches attended beginning in childhood______

Religious background of spouse (if married) ______

Spouse currently attends church? _____

Do you believe in God? ______I pray Often _____ Occasionally _____ Never _____

If you were to die you would go to heaven? ______Explain:______

______

I read the bible Often _____ Occasionally _____ Never _____

Are you involved in volunteer work or ministry anywhere?______Describe ______

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PROBLEM CHECKLIST

_____Anger_____Envy_____Appetite

_____Anxiety_____Fear_____Memory

_____Apathy_____Gluttony_____Moodiness

_____Bitterness_____Guilt_____Rebellion

_____Change in lifestyle_____Health_____Sexual issues

_____Children_____Self-destructive habits_____Sleep

_____Depression_____Impotence_____Physical Abuse

_____Deception_____In-laws_____Other

Check all that apply. Circle the 3 most urgent. Add any explanation or other issues: ______

______

______

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BASIC PROBLEM(S) THAT LED YOU TO SEEK COUNSELING

Briefly answer the following questions:

  1. What is the main problem, as you see it?
  1. What have you done about it?
  1. What can we do? What are your hopes or expectations in coming here?
  1. What other information will enable us to help you effectively?