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Biblical Counseling Intake Form
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Work Entry
Added: 7/22/2026
First Name
First Name cannot contain special characters such as quotes, parentheses, etc.
First Name cannot contain emojis or special fonts.
First Name is required.
Last Name
Last Name cannot contain special characters such as quotes, parentheses, etc.
Last Name cannot contain emojis or special fonts.
Last Name is required.
Email
Email address is not valid
Email is required.
Gender
Male
Female
Gender is required.
Availability
Availability is required.
Age
Age is required.
Employer
Employer is required.
Marital Status
Single
Engaged
Married
Separated
Divorced
Widowed
Other
Marital Status is required.
Spouse's Name
Spouse's Name is required.
Years Married
Years Married is required.
Children?
Yes
No
Blended Family
Children? is required.
Names and Ages of Children
Names and Ages of Children is required.
Are you a Christian? Please describe why you believe so.
Are you a Christian? Please describe why you believe so. is required.
Are you a member of Redeemer Bible Church?
Yes
No
In the process
Are you a member of Redeemer Bible Church? is required.
When did you start attending Redeemer?
When did you start attending Redeemer? is required.
Do you personally know a pastor/elder at Redeemer?
Do you personally know a pastor/elder at Redeemer? is required.
Have you been baptized?
Yes
No
In the process
Have you been baptized? is required.
How often do you read the Bible?
Never
Rarely (a couple times a year)
Occasionally (a couple times a month)
Weekly
Daily
How often do you read the Bible? is required.
How often do you physically attend church?
Never
Christmas and Easter
Once or twice a month
Weekly
How often do you physically attend church? is required.
How are you involved at church?
How are you involved at church? is required.
Do you have a Growth Group? Which one?
Do you have a Growth Group? Which one? is required.
Problem Check List
Assurance
Bipolar Disorder
Bitterness
Body Image
Change in lifestyle
Children
Communication
Conflict (fights)
Deception
Decision Making
Depression
Drinking / Drunkenness
Envy
Fear
Health
Homosexuality
Illegal Drugs
Impotence
In-laws
Loneliness
Lust
Lying
Moodiness
Past Issues (PTSD)
Perfectionism
Pornography
Rebellious Heart
Sex
Sleep
Transgenderism
Worry
Wife Abuse
Husband Abuse
Other
Problem Check List is required.
Please describe your physical health
Please describe your physical health is required.
Do you have any recurring conditions?
Do you have any recurring conditions? is required.
Average hours of sleep each night.
Average hours of sleep each night. is required.
Do you smoke?
Cigarettes
Marijuana
Vape
No
Do you smoke? is required.
Do you drink?
Rarely (once or twice a year: perhaps a holiday)
Sometimes (once or twice a month)
Often (one or twice a week)
Regular (more than twice a week)
Weekend binger
None
Do you drink? is required.
Have you been diagnosed with any mental health illnesses?
Have you been diagnosed with any mental health illnesses? is required.
Current Medication(s) and dosage(s)
Current Medication(s) and dosage(s) is required.
Have you ever seen or are currently seeing a psychiatrist or secular counselor?
Have you ever seen or are currently seeing a psychiatrist or secular counselor? is required.
What issue or situation are you presently seeking counsel for?
What issue or situation are you presently seeking counsel for? is required.
What have you tried to do about this issue?
What have you tried to do about this issue? is required.
What are your expectations from counseling?
What are your expectations from counseling? is required.
Have you met with anyone from Redeemer before for help?
Have you met with anyone from Redeemer before for help? is required.
Submit