Faith-Based Counseling Intake Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact
Name
Relationship
Phone Number
Faith Background
Religious Affiliation / Denomination
Church/Place of Worship (if any)
How important is faith in your life?
Very Important
Somewhat Important
Neutral
Not Very Important
Presenting Issues
Briefly describe why you are seeking counseling
How long have you been experiencing these concerns?
What would you like to achieve through counseling?
Previous Counseling Experience
Have you received counseling before?
Yes
No
If yes, please provide details