I'm glad you're here! As a coach, it's important for me to understand how you view the world in general and yourself in particular. Each person has a unique way of thinking and a unique way of interacting with those around him or her. Please answer each of these questions as clearly and thoughtfully as possible, expressing the best of who you are. These are "pondering" questions designed to stimulate your thinking in a particular way that will make our work together even more productive.

​Everything in this form will remain confidential with the following exceptions: (a) you direct me in writing to disclose information with someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) we are ordered by a court to disclose information. I look forward to learning more about you as we begin our work together!

Counseling Intake Form 




The basics...

What, if any, personaity tests have you taken?

Please answer the following questions...

I am responsible for my own outcomes.
Constructive critism helps me grow
Women cannot be trusted.
I read my bible at least 4 tims a week
I am prepared to make the changes I need to make in order for me to reach my goals.
I believe that God has my best interest in mind.
I have time and am commited to doing the homework that is asigned to me.
Prayer is a powrful tool for change.
The bible makes sense to me.
Other people are responsible for the way I am right now.
I am confident in my ability to make the chages I need in order for me to reach my goals.
I am able to hear from the Holy Spirit throughout th day.
I am able to connect with God in my quiet time.
People cannot be trusted.
God is my refuge in times of trouble.
Going to church on Sunday is important to me.
I believe tht God loves me.
I am able to develop deep pesonal reltonships with others.
Church leaders cannot be trusted.
Community is important to happiness.
I need people.
I make imprtant contributions to the people in my life.
I am likeable.
People want to be around me.
I often hold my breath when I am stressed.
I give up when things get hard.

Personal, Family, & Relationships:

Has a significant person or family member entered into your life or left your life in the last 90 days?
What is your marital status now? (Please check all that apply)
Have you ever had problems in your marriage or relationships?
If yes, please check a reason why:



What is your work history like?
How long do you usually stay in your job?
Have you ever served in the military?
If yes, what is your status?