Biblical Counseling Application | Parkway Baptist Church

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip / Post Code *

Email *

Phone *

Age

Sex

Employer

Current Employment Position

Work Hours/Schedule

Other Significant Time Commitments

Marital Status

Spouse Name

Date of Marriage

Please describe your marriage

Please list any previous marriages

Please list any children with names and ages

Please describe your relationship with your father

How man siblings do you have?

Please describe your relationship with you mother

Briefly describe your childhood and upbringing

Who are your trusted friends and most influential relationships?

Please describe your overall health

Date of last medical exam

Please list any chronic conditions, illnesses, injuries, or disabilities

Please list any prescribed medications

Please list any allergies

Please describe any present or history of drug use for anything other than a medical purpose

Describe any consumption of beverage alcohol (how many drinks per day and how many days per week)

Describe your sleeping habits

Have you ever been under the care of a mental health professional? If so, please describe.

Have you ever thought about harming yourself or others? If so, please explain.

Have you ever been arrested? If so, please explain.

Describe your faith background

Are you a Christian? If so, please describe your conversion.

What is the gospel?

Have you been water baptized as a Christian? If so, please describe.

What church do you attend?

Does a pastor/elder from your church know that you are requesting counseling?

How often do you read the Bible?

Describe your prayer life

Why are you seeking counseling? Please describe the difficulties you are facing. *

What have you done about the difficulties? Pleased describe what has worked or not worked so far. *

What are your expectations from counseling? *

What do you think needs to change? *

What other information do you think we should know or you would like to share? *

Please Check All That Apply To You *

Anger
Anxiety
Apathy
Bad Memories
Bitterness
Children
Communication
Conflict
Decision-making
Depression
Discouragement
Domestic Violence
Drunkenness
Envy
Fear
Finances
Gluttony
Guilt
Grief
Homosexuality
Infertility
In-laws
Laziness
Loneliness
Lust
Marriage Problems
Moodiness
Overwhelmed
Perfectionism
Pornography
Priorities
Procrastination
Sexual Immorality
Sexual Issues in Marriage Relationship
Time Management
Weariness

If you are interested in receiving biblical counseling, please submit the following application and we will be in touch with you to schedule an appointment.