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Biblical Counseling Intake Form

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Work Entry

Person Information

Note: If you are seeking Marriage or Couples Counseling, each individual must submit a questionnaire.

Campus

Campus is required.

First Name

First Name cannot contain special characters such as quotes, parentheses, etc.First Name cannot contain emojis or special fonts.

First Name is required.

Last Name

Last Name cannot contain special characters such as quotes, parentheses, etc.Last Name cannot contain emojis or special fonts.

Last Name is required.

Email

Email address is not valid

Mobile Phone

Birthdate

/ / Birth Date cannot be a future date.

Gender

Male Female

Address

Preferred Language

Counseling Request Details

Marital Status

Marital Status is required.

Employer and Title

Employer and Title is required.

Do you have children?

Do you have children? is required.

How long have you been attending Gateway Church?

How long have you been attending Gateway Church? is required.

Do you attend a Gateway Group?

Do you attend a Gateway Group? is required.

What are you involved in at Gateway Church?

What are you involved in at Gateway Church? is required.

Do you prefer morning or afternoon appointments?

Do you prefer morning or afternoon appointments? is required.

Have you struggled with any of the following in the past?

Feelings of Inferiority Suicidal Thoughts Suicidal Attempts Angry Thoughts Rejection Unforgiveness Family History of Mental Illness Angry Outbursts Eating Disorders Lustful Thoughts Depression Excessive Anxiety of Worry Excessive Fear Spiritual Abuse Physical Abuse Verbal Abuse Emotional Abuse Sexual Abuse Sexual Addiction Substance Abuse/Addiction Gambling Addiction Under Too Much pressure/Feeling Stressed Nightmares Feeling Trapped in Rooms/Buildings Obsessive Thoughts Suspicious Feelings Towards Others Feeling Numb or Cut Off From Emotions Blackouts or Temporary Loss of Memory Concerns About Emotional Stability Sleep Difficulty - Not Enough or Too Much Loss of Appetite or Increased Appetite Overeating then Vomiting to Control Weight Excessive Use of Alcohol Abuse of Prescription Drugs Getting into Trouble at Work/School Not Being Able to Say What You Really Think or Feel Feelings as if You Would be Better Off Dead Feeling Manipulated of Controlled by Others Difficulty Making Decisions Loss of Interest in Sexual Relationships Feeling Sexually Attracted to Members of Your Own Sex Compulsive Behavior Inability to Concentrate at School or Work Loss of Interest in Usual Activities/Lack of Motivation Crying Spells Inability to Control Thoughts Feeling Like You are Being Watched Hearing Voices

Are you currently struggling with any of the following?

Feelings of Inferiority Suicidal Thoughts Suicidal Attempts Angry Thoughts Rejection Unforgiveness Family History of Mental Illness Angry Outbursts Eating Disorders Lustful Thoughts Depression Excessive Anxiety of Worry Excessive Fear Spiritual Abuse Physical Abuse Verbal Abuse Emotional Abuse Sexual Abuse Sexual Addiction Substance Abuse/Addiction Gambling Addiction Under Too Much pressure/Feeling Stressed Nightmares Feeling Trapped in Rooms/Buildings Obsessive Thoughts Suspicious Feelings Towards Others Feeling Numb or Cut Off From Emotions Blackouts or Temporary Loss of Memory Concerns About Emotional Stability Sleep Difficulty - Not Enough or Too Much Loss of Appetite or Increased Appetite Overeating then Vomiting to Control Weight Excessive Use of Alcohol Abuse of Prescription Drugs Getting into Trouble at Work/School Not Being Able to Say What You Really Think or Feel Feelings as if You Would be Better Off Dead Feeling Manipulated of Controlled by Others Difficulty Making Decisions Loss of Interest in Sexual Relationships Feeling Sexually Attracted to Members of Your Own Sex Compulsive Behavior Inability to Concentrate at School or Work Loss of Interest in Usual Activities/Lack of Motivation Crying Spells Inability to Control Thoughts Feeling Like You are Being Watched Hearing Voices

Which of the following have you experienced or completed as part of your Spiritual Walk?

I've given my life to Christ Water Baptism: I've been water baptized by submersion Holy Spirit: I'm infilled by the Holy Spirit Prayer Language: I have a prayer language

Please describe your relationship with the Lord:

Please describe your relationship with the Lord: is required.

Please describe any inner healing/deliverance you have walked through and when it occurred:

Please describe any inner healing/deliverance you have walked through and when it occurred: is required.

How would you rate your overall physical health?

How would you rate your overall physical health? is required.

Do you find discussing your life circumstances easy or difficult? Please explain:

Do you find discussing your life circumstances easy or difficult? Please explain: is required.

Emergency Contact Name (other than a spouse):

Emergency Contact Name (other than a spouse): is required.

Emergency Contact Phone:

Emergency Contact Phone: is required.

Care Team Details

What has led you to seek ministry/assistance?

What has led you to seek ministry/assistance? is required.

What are your expectations or hopes for receiving ministry?

What are your expectations or hopes for receiving ministry? is required.

Did anyone refer you for ministry?

Did anyone refer you for ministry? is required.

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