Sign up for counseling

So you are considering receiving counseling at SVRBC… Great! In order for us to give the best counsel we can beginning with the first session, we’ll need some information from you. Complete this form and we will get back to you.

This form is confidential and the data you submit will not be shared. See our privacy policy for more information.

Name

Phone number

Address

City

State

Zip Code

Date of birth

Month

Day

Year

Sex

Highest level of education

Other training (list type and years)

Hobbies

Family life link

Marital status

Spouse's name

Spouse's occupation

Spouse's religion

Spouse's age

Spouse's highest level of education

Years married

How long did you know your spouse before marriage?

Have you ever been separated?

When and for how long were you separated?

When did your separation begin?

Does your spouse know you are coming for counseling?

Is your spouse willing to come to counseling?

Give brief information about any previous marriages, for you or your spouse

Do you have children?

Please list the names and ages of your children, and if they live with you

Health information link

Rate your overall health

Approximately how many hours of sleep do you get each night?

At what time do you typically go to sleep at night?

At what time do you typically get up?

Approximately how many hours per day do you spend per day on the following activities?

Work

Social media

Video games

Prayer and/or Bible reading

List all important present and past illness, injuries, or handicaps

Are you currently taking medication?

List medications

Do you use drugs for other than medical purposes?

What drugs and how often?

Religious background link

What religion or denomination do you consider yourself?

Do you regularly attend a church?

What church?

May we contact your church?

How many church services do you attend per month?

What religion were you raised in as a child?

Do you believe in God?

How often do you pray to God?

How often do you read the Bible?

Are you saved?

Would you be able to say for certain that if you were to die today, you would go to heaven?

If you were to die today, and God asked you "Why should I let you into heaven?" What would you say?

Explain any recent changes in your religious life, if any

Counseling issues link

What are the issues you are struggling with?

What have you done about these issues?

What are your expectations from counseling?

Is there any other information we should know?

How did you hear about biblical counseling at SVRBC?

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