The Basics of Biblical Counseling - Biblicalcounselingonline.org

RELIGIOUS BACKGROUND:
Denominationalpreference:____________________________________________
Membership:________________________________________________________
Churchattendance per month (circle): 0 1 2 3 4 5 6 7 8 9 10+
Churchattended in childhood:_______________________ Baptized? Yes No
Religious background of spouse (if married):________________________________
Do you believe inGod? Yes No Uncertain
Do you pray to God? Never Occasionally Often
Are you saved? Yes No I mnot sure what you mean
How frequently do you read the Bible? Never Occasionally Often
Do you have regular family devotions? Yes No
Explain any recent changes in your religious life:____________________________
___________________________________________________________________
MARRIAGE AND FAMILY INFORMATION:
Name of spouse:________________ Phone: (___) ____ - _____
Address (if different):___________________________________________________
Occupation:_____________________________ Business phone: (___) ____ - _____
Spouse's age:___ Education (in years):______ Religion:_______________________
Is your spouse willing to come for counseling? Yes No Uncertain
Have you ever been separated? Yes No When?_________________________
Has either of you ever filed for divorce? Yes No When?__________________
Date of marriage:_________ Ages when married: Husband:___ Wife:___
How longdid you know your spouse before marriage?_________________
Length of dating with spouse:___________ Length of engagement:_____________
Give brief information about any previous marriages:_________________________
____________________________________________________________________
Information about children:
PM* Name Age Sex
Currently
Living?
Education
Marital
Status
*Check this column if child is by a previous marriage.
If you were reared by anyone other than your parents, briefly explain:
___________________________________________________________________
How many older siblings do you have? ___ brothers ___ sisters
How many younger siblings do you have? ___ brothers ___ sisters
Have there been any deaths in the family during the last year? Yes No
Who and when:________________________________________________________
160