Lifepointe Biblical Counseling Application
Please fill out this form and click submit.
Personal Information
Name
*
Birthday
*
Gender
*
Please select one option.
Male
Female
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Phone
*
Email
*
Family Information
Status
*
Please select all that apply.
Single
Married
Seperated
Divorced
Widow
Name of Spouse
*
Have you been married previously?
*
Please select all that apply.
Yes
No
Names and ages of children
*
Have there been any deaths in the family during the past two years?
*
Employment Information
Are you currently employed? If so, where?
*
How long have you been at this position?
*
Is your spouse currently employed? If so, where?
*
How long has he/she been at this position?
*
Spiritual Information
Do you believe in God?
*
Please select all that apply.
Yes
No
Uncertain
Do you pray to God?
*
Please select all that apply.
Regularly
Occassionaly
Never
Do you read the Bible
*
Please select all that apply.
Regularly
Occassionally
Never
What church do you attend?
*
How many times per month do you attend church?
*
Current Pastor
*
Pastor's Phone Number
*
Consent to contact Pastor
*
Please select all that apply.
Yes
No
Have you received Jesus Christ as your Savior?
*
Please select all that apply.
Yes
No
If yes, when?
Have you been baptized in water since you received Christ?
*
Please select all that apply.
Yes
No
If yes, when?
Have you been involved in any cults or occult practices?
*
Please select all that apply.
Yes
No
If yes, explain:
*
Health Information
Rate your health:
*
Please select all that apply.
Very Good
Good
Average
Poor
Please list any significant illnesses, injuries, or disabilities:
*
Please list any medication(s) you are presently taking:
*
Have you had a medical exam in the past year?
*
Please select all that apply.
Yes
No
Have you had any professional counseling before?
*
Please select all that apply.
Yes
No
Has your weight changed significantly in the past year?
*
Please select all that apply.
Yes
No
Have you ever or do you now use alcohol or drugs?
*
Please select all that apply.
Yes
No
Explain what the main problem is as you see it? What brings you here?
*
How can we help? What are your expectations in coming here?
*
What have you done to resolve this problem?
*
Please describe what person(s), situation(s), or activities that seem to trigger this problem or make it worse.
*
What, if anything, do you fear?
*
Is there any other information that we should know?
*
Submit
Description
Please fill out this form and click submit.
×
Please Fix the Following