Information Form for Biblical Counseling at Christ Chapel
In order for us to best serve you, this form needs to be completed in its entirety, unless otherwise directed or the question does not pertain to you in any way. Please do not alter the format of this document.
Date: ______
Personal Information:
Name: ______Age: ______Sex: ______Birth Date: ___/____/_____
Mailing Address______Phone (h): (___) ______
City, State, Zip ______Phone (w): (___) ______
Email: ______Phone (c): (___) ______
Is it ok to send mail to your address if necessary? ( ) Yes ( ) No
For Confidentiality, when and where do you prefer to be reached? ______
Emergency Contact: Name: ______Phone: (___) ______Relationship: ______
Who referred you or how did you hear about us? ______
(Website, Church bulletin, Soul Care Group, CCBC Pastor, Friend, Other,) Please name person above
Family Information:
Martial Status: Never Married ______Married ____ Separated ____ Divorced ____ Widowed ____
Wedding Date of Current Marriage: ___/____/_____ Number of Marriages: ______
Spouse’s Name (if married): ______Date of Birth: ___/____/_____
Have you ever been separated? ______If so, when? From ___/____/_____to ___/____/_____
Has either of you filed for divorce? ____ If so, when? ______
Number of Children/ages: ______
Any other information about your family that would be helpful to know: ______
______
Scheduling Information:
Do you have a spiritual friend that that would be willing to come in with you? ( ) Yes ( ) No
If so, what is their name? ______
Please list specific days/times for your appointment availability:
Monday morning Tuesday morning Wednesday morning Thursday morning Friday morning
afternoon afternoon afternoon afternoon afternoon
evening evening evening evening evening
Any other information about scheduling that would be helpful: ______
______
______
Health/Medical Information:
Rate your health (Check one): Excellent ___ Good ___ Average/Fair ___ Poor ___Other ____
Have there been any significant weight changes in the past year? ______
List any major present or past illnesses, injuries, or handicaps: ______
______
Are you presently taking any medications? ______
If so, please list the medications and their purpose:
______
______
______
______
______
Date of last medical examination: ___/____/_____ Your physician:______Most recently hospitalized for medical reasons: Date:______Reason ______
Have you ever had any psychotherapy or counseling before? ( ) Yes ( ) No
If yes, list the counselor/therapist and time period: ______
______
Were you satisfied with the results from previous counseling? ______
If applicable, is your spouse willing to come in for counseling? ______
Occupational/Educational Information
Occupation: ______
Level of Education: ______Date(s): ______
If currently a student: Field of study: ______Part-time Full-time
Institution, University or College: ______
Religious Information:
Do you attend church? ( ) Yes ( ) No If yes, where? ______
If Christ Chapel, what is your affiliation? (Check one) Member__ Regular Attendee __New Attendee__ Other__
Where did you attend church growing up? ______Are you a Christian? ( ) Yes ( ) No
Please describe how your relationship with Christ began: ______
______
Please describe how your relationship with Christ has progressed: ______
______
Explain recent changes in your religious/spiritual life, if any: ______
______
______
Personality Information:
Have you ever experienced a severe emotional upset experience that negatively effected your daily functioning? ( ) Yes ( ) No
If yes, please explain______
______
Please list any addictions: ______
Have you ever had hallucinations? _____ How many hours of sleep do you get a night? ______
Do you ever feel suicidal? _____ If so, please explain? ______
______
Do you feel depressed? No _____ Mildly _____ Moderately _____ Severely _____
Do you feel overwhelmed? ______If so, explain: ______
______
______
______
Please check how often the following thoughts occur to you?
1. Life is hopeless. ___Never ___Rarely ___Sometimes ___Frequently
2. I am lonely. ___Never ___Rarely ___Sometimes ___Frequently
3. No one cares about me. ___Never ___Rarely ___Sometimes ___Frequently
4. I am a failure. ___Never ___Rarely ___Sometimes ___Frequently
5. Most people don’t like me. ___Never ___Rarely ___Sometimes ___Frequently
6. I want to die. ___Never ___Rarely ___Sometimes ___Frequently
7. I want to hurt someone. ___Never ___Rarely ___Sometimes ___Frequently
8. I am stupid. ___Never ___Rarely ___Sometimes ___Frequently
9. I am going crazy. ___Never ___Rarely ___Sometimes ___Frequently
10. I can’t concentrate. ___Never ___Rarely ___Sometimes ___Frequently
11. I am depressed. ___Never ___Rarely ___Sometimes ___Frequently
12. God is disappointed in me. ___Never ___Rarely ___Sometimes ___Frequently
13. I can’t be forgiven. ___Never ___Rarely ___Sometimes ___Frequently
14. Why am I so different? ___Never ___Rarely ___Sometimes ___Frequently
15. I can’t do anything right. ___Never ___Rarely ___Sometimes ___Frequently
16. People hear my thoughts. ___Never ___Rarely ___Sometimes ___Frequently
17. I have emotional numbness.. ___Never ___Rarely ___Sometimes ___Frequently
18. Someone is watching me. ___Never ___Rarely ___Sometimes ___Frequently
19. I hear voices in my head. ___Never ___Rarely ___Sometimes ___Frequently
20. I am out of control. ___Never ___Rarely ___Sometimes ___Frequently
Please comment about each of the above thoughts that occurred frequently or are a concern to you: ______
______
______
______
______
______
BRIEFLY ANSWER THE FOLLOWING QUESTIONS:
1. What is the main problem as you see it? (What is your reason for coming to Soul Care?)
A. . Please rate the severity of your present concerns on the following scale. Check one:
Mild Moderate Severe Totally Incapacitating
B. What areas of your life are being most affected by this problem? (Check all that apply):
Home Work Marriage Other Relationships God Church/ministry
Other ______
Please Explain:
C. How long has this problem existed?
D. How have you attempted to resolve it before seeking help through CCBC?
E. How would things be different for you if this issue was remedied?
2. What I desire more than anything else in life is:
3. What I fear most in life is:
4. What results/expectations do you have in coming here for counseling?
5. Is there any other information that we should know (if you need more room, use the reverse side)?
4
3740 Birchman Ave. Fort Worth, TX 76107. phone: (817) 546-0827 fax: (817)-731-4662. www.ccbcsoulcare.org
.