Jay E. Adams - Ready to Restore: An Introductory Guide to Biblical Counseling

Name _______________________________________________________

Cell Phone # __________________________________________________

Street Address _________________________________________________

City ___________________________ State ________ Zip ______________

Todays date _________ E-mail address _______________________________

Sex ______ Date of Birth ______________________ Age ________________

Referred here by ________________________________________________

Have you received counseling or psychotherapy before?

Yes No

If Yes, list counselors and approximate dates: _____________________________

____________________________________________________________

What was the outcome? ___________________________________________

Have you ever been arrested? Yes No

If Yes, explain briefly _____________________________________________

How long have you lived in this area? __________________________________

Where are you from? _____________________________________________

Health Information

Rate your health

Very good Good Average Declining Failing

Height ____________ Approximate weight ____________________________

Recent weight changes ____________________________________________

List every physician you have seen in the last two years (list regular physicianfirst):

Doctor ______________________ Reason __________________________

Doctor ______________________ Reason __________________________

Doctor ______________________ Reason __________________________

Doctor ______________________ Reason __________________________

Date of last physical examination _____________________________________

Results ______________________________________________________

List all important illnesses, injuries, or handicaps (past or present)

___________________________________________________________

___________________________________________________________

___________________________________________________________

____________________________________________________________

Are you presently taking any medication? Yes No

If Yes, list the medications and the Doctor that prescribed them (include all over-the-countermedications you use) ________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

___________________________________________________________

Have you ever used drugs for other than medical purposes?

Yes No

What and when? _______________________________________________

How many hours of sleep do you average per night? ________________________

Have there been any recent changes? __________________________________

Is this sleep restful? _____ Do you have trouble sleeping? _____________________

Do you smoke? Yes No

Drink alcohol, even moderately? Yes No

Religious Background

Church currently attending _________________________________________

How long? ____________________________________________________

Church street address _____________________________________________

City ____________________ State _____ Zip ________________________

Churchs denomination or affiliations __________________________________

Church phone __________ Pastors name _____________________________

Have you discussed this problem with your pastor? _________________________

Does your pastor know you are seeking counsel from us?

Yes No

Are you a member of your church? Yes No

Baptized? Yes No

Church attendance, times per month (circle)

0 1 2 3 4 5 6 7 8 9 10+

Have you ever been disciplined by a church? Yes No

If Yes, explain __________________________________________________

Have you ever left a church for any reason other than moving from the community?____ If so, explain briefly ___________________________

____________________________________________________________

Religious background in childhood ___________________________________

Do you consider yourself a religious person? Yes No Uncertain

Do you believe in God? Yes No Uncertain

Do you pray to God? Never Occasionally Often

Are you saved? Yes No Not sure what you mean

Do you believe you will go to heaven when you die? __________________________

Do you read the Bible? Never Occasionally Often

Explain any changes in your religious life in the last three years

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Marriage and Family Information

Name of spouse ________________________________________________

Date of marriage ________________________________________________

Address if different ______________________________________________

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Cell phone # _____________ Work phone # _____________________________

Occupation ______________ Employer _______________________________

Spouses birthday _________________ Age ___________________________

Spouses education ______________________________________________

Is your spouse willing to come with you for counseling? Yes No Uncertain

Your ages when married: Husband ________ Wife ________________________

Length of engagement ____________________________________________

How long did you know your spouse before marriage? _______________________

Have you ever been separated? Yes No

When? From ________________ to ________________________________

Has either of you ever filed for divorce? Yes No

When? ______________________________________________________

Give brief information about previous marriages ___________________________

____________________________________________________________

Information about children:

Check the PM column if child is by a previous marriage.

Briefly describe the home you grew up in ________________________________

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_____________________ Where? _________________________________

How many older brothers _______________ sisters______________ do you have?

How many younger brothers ______________ sisters _____________ do you have?