form

By Faith

Life Coaching and Biblical Counseling Intake Form

Full Name

Date of Birth

Age

Male

Female

Address

City

State

Zip

Primary Phone

Home

Cell

Work

Emergency Contact

Relation

Phone

Information About Why You Would Like to Meet with a Life Coach/Biblical Counselor
(Please be as honest as possible. There are no right or wrong answers and your honest responses will help me with a plan for the best success!)

What is the main reason you want to meet with me?

On a scale of 1-10 how important is it to reach your goal?

1=Not at all 10= Very Important

On a scale of 1-5 how much do you like to:
1=Not at all 5=I love it!

Read

Journal

Watch informational videos such as YouTube

How much time do you have to work on the process to move you to where you want to be?
(Check all that apply.)

I am too busy and do not have time other than the time we spend together.

I have a minimum amount of hours I can work on this per week.

I will do the work that you give me to the best of my ability.

Do you think you have things in the past that are holding you back from becoming the person God wants you to be?

Yes

Unsure

If yes, what do you think holds you back the most?

Are you interested in:

Life coaching only

Biblical counseling only

Both, or whatever we need to do to get me to my goal(s)

How do you generally handle a challenge?

What motivates you the most?

General Informatiom

Education Completed

I am working:

Full-time

Part-time

Self-Employed

Stay-at-home Parent

Student

Unemployed

Other

How did you hear about us?

Have you ever worked with a Life Coach or a Biblical Counselor before?

If Yes, Briefly describe the reason you worked with one and how it went for you:

If 'Other', please specify:

Relationship Status:

Questions of Faith

What faith, tradition, or religious affiliation were you raised with?

Current faith tradition or religious affiliation:

Have you received Jesus Christ personally as your Savior?

If yes, Please answer questions 1-3:

1.) How do you know that Jesus Christ is your Savior?

2.) What Changes took place in your life when you became a believer?

3.) Have you told household / Family members about receiving Jesus as Savior?

Do you read the Bible?

If often, how often?

Do you have personal Devotions?

If often, how often?

Describe your personal devotions:

Explain any recent changes in your spiritual life:

Do you feel close to God? Why or why not?

Information About Personal Habits and Health

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

When do you normally:

Go to bed?

Fall asleep?

Wake up?

Get out of bed?

If there is a length of time between going to bed and falling asleep, what do you do during that time?

If there is a length of time between waking up and getting out of bed, what do you during that time?

Describe any recent changes in sleep habits?

State of health:

Please explain if 'Other' or if there is anything you would like me to know:

Date of last medical examination:

Results (Please explain if there are any physical or mental issues I should know about):

Are you presently taking medications?

If yes:

Medication?

Dosage?

Reason for medication?

Medication?

Dosage?

Reason for medication?

Medication?

Dosage?

Reason for medication?

Medication?

Dosage?

Reason for medication?

Have you or do you now used drugs for recreational purposes?

If yes, when?

What?

Amount/Dosages?

What?

Amount/Dosages?

What?

Amount/Dosages?

Do you drink alcoholic beverages?

How Often?

How much? Per week:

Have you ever had a severe emotional upset?

If yes, please explain:

List all important present or past illnesses, injuries or handicaps:

Marriage and Family Information

Are you married?

Yes

If yes, how long?

Is your spouse a Christian?

Have you been married before?

Yes

If yes, how many times?

Do you have any children?

Yes

If yes, how many?

Boys:

Ages:

Girls:

Ages:

Do you have any siblings?

Yes

How many brothers?

How many sisters?

Are they all biological?

Yes

If yes, where do you fall in the birth order?

Thank you for taking the time to complete this survey.
Please choose 'Continue' to move forward with the payment process.

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