Christian Marriage Counseling Intake Form
Personal Information
Husband's Name
Wife's Name
Husband's Age
Wife's Age
Phone Number
Email Address
Home Address
Marriage Information
Date of Marriage
Years Married
Number of Children and Ages
Church Affiliation
Pastor's Name
Spiritual Background
Please describe your relationship with God.
How often do you pray together?
Do you attend church together?
Regularly
Sometimes
Rarely
Never
Presenting Issues
Briefly describe the main concerns that brought you to counseling.
Have you previously attended any counseling? If yes, give details.
What are your goals for counseling?
Additional Comments
Is there anything else you would like us to know?