Data Gathering – Biblical Solutions

Data Gathering Form

Biographical Information

Just the Basics

First Name

Last Name

Home Address

Street Address

Apartment Unit #

City

State

Zip Code

Best Phone Number

Date of Birth

Age

Relationship & Occupation

Personal Connections & Career

Provide some brief detail regarding your Relationship Status

How many children/ages - if none put N/A

Occupation & Employer

Spouse's Name (if applicable)

Spouse's Occupation & Employer (if applicable)

Church History

Past & Present

Childhood Church

Present Church

How often do you attend?

Weekly

Sporadic

A few times a month

Holidays only (Easter, Thanksgiving, Christmas)

Other Churches Attended

Why You're Here

The Heart of the Matter

Purpose of our time together from your perspective:

What have you done about it before coming to Biblical Solutions?

If you checked any, please describe:

Have you experienced or are you currently experiencing abuse in any of the following areas? (Select all that apply.)

Physical

Sexual

Verbal

Emotional/Psychological

Financial

Neglect

Spiritual/Religious

Digital/Technological (e.g., cyberbullying, monitoring through devices)

Other (please specify below)

If you checked any, please describe:

Self Perception

Looking Inward

As you see yourself, what kind of person are you?

What, if anything, do you fear?

What three words would you use to describe yourself?

Health & Habits

Daily Life

Eating habits/diet

Undereat

Overeat

Balanced

When was the last time you accessed/used pornography in any form?

When was the last time you played video games in any form?

If you play video games, how often do you play/how many hours per session? What is your go-to game?

List any major illnesses or hospitalizations. If none, put N/A.

What medications, supplements or prescription drugs are you taking? If none, put N/A.

What illegal drugs or recreational drugs are you currently using or have used in the past? If none, put N/A.

Have you been treated for any mental or physical health conditions (emergent or ongoing) in the last two years?

List any other health problems, no matter how insignificant it may be:

If you checked any of the options above, please expand:

What are your hobbies?

Family History

Growing Up

Father

Living

Deceased

Father's current age or age at time of death and cause of death:

Mother

Living

Deceased

Mother's current age or age at time of death and cause of death:

Describe your family growing up: Parents married, divorced, step-parents, siblings, major events, etc. This does not need to be exhaustive, just a quick recap.

Faith Journey

Where are you Spiritually?

Are you a Christian?

Yes

I'm not sure

If you are a Christian, please share the journey or significant moments that led you to accept Christ as your Savior.

Final Questions

You're Almost Done!

Is there any other information we should know?

Emergency Contact (name, number, relation to you)

Today's Date