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Data Gathering

We appreciate you taking the time to provide us with some initial information about yourself and your needs. Your truthful and honest answers will help us understand your background, current situation, and what you hope to achieve through Biblical Counseling. Please answer each question as thoroughly as possible. Your responses are confidential and will be used to tailor our services to support you best. If you need assistance or have questions, don’t hesitate to reach out. We estimate that completing this form will take about five minutes. We look forward to supporting you on your journey towards hope and healing.

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

Email

Date of Birth

Age

Relationship & Occupation

Personal Connections & Career

Relationship Status

Single - never been married

Married

Married but separated

Divorced

Widowed

Other

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?

Are you experiencing issues in any of the following areas in your life?

Spiritual

Psychological

Social

Physical

Financial

Marital

Parental

Depression

Anxiety

Anger (in any form)

Alcohol misuse

Stress (in any form)

Illegal Drugs (including marijuana)

Prescription Drugs

Tobacco use (cigarettes, smokeless, vaping)

Communication

Unable to control or slow down thoughts - mind races

Unable to focus thoughts or stay on task - mind wanders

OCD

ADD/ADHD

PTSD (unprocessed trauma)

Suicidal Thoughts or Ideations

Adult Children

Aging Parents

Empty Nest

Job/Work

In-laws

Pornography

Church Issues

Other

If you checked any, please describe:

Are you experiencing issues in any of the following areas in your life?

Physical

Sexual

Verbal

Emotional/Psychological

Financial

Other

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:

Do you do any of the following?

Exercise

Use tobacco in any form

Vape

Consume caffeine

Sleep well at night

Sleep poorly at night

Drink alcohol

Take vitamins or other supplements

Other

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:

Rate the moral atmosphere in which you were raised during the first 18 years of your life:

Overly Permissive

Permissive

Average

Strict

Overly Strict

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

No

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