New Client Data Inventory Form

Dear New Client,

Welcome to PeaceBrooke Biblical Counseling! This form must be filled out by or for each counselee. Adult counselees must sign it electronically. In the case of a minor or an adult under legal guardianship, the parent or guardian must sign it. However, the counselee can fill it out—or the parent or guardian can interview the counselee to fill it out, if that seems appropriate.

If you are simply going to be an observer of the counseling process, please do not fill out this form. However, you must sign Peacebrooke's Terms, Conditions & Privacy Notice/Agreement. Click here to read and sign it.

Please plan to take at least 15 minutes to fill out this form. All required questions are marked with an asterisk (*). If any of the questions that are not required don't apply to the service you have requested, or you do not want to answer them, you can skip them. Though you do not have to answer all of the questions that apply to your situation, it is highly recommended that you do so for the following reasons:

It will save you money, because your counselor will need to ask you fewer questions during counseling sessions.
It will enable your counselor to get to know you better so that he or she can counsel you more effectively, be more empathetic, and better meet your needs.

Your counselor has had his or her fair share of let-downs, failures, and struggles, so please do not be concerned that your counselor will judge you or look down on you because of any information that you share here. We are ALL error-prone human beings in need of God’s help, mercy, and forgiveness. Your counselor has found help in his or her own life through Christ and His inspired Word, and wants to help you find it, too! Filling out this form will better enable your counselor to do that.

Which of our services are you using?

If you chose "Help With Something Else," please very briefly describe it. You will have opportunity to explain more below.

Name of Counselee

First Name

Last Name

Please provide the names of all persons who will be receiving counseling along with you. Please inform them that they must also fill out this form.

Please provide the names of all persons who will be observing the counseling process, but not receiving counseling. Please inform them that although they do not need to fill out this form, they must fill out our Terms, Conditions & Privacy Notice/Agreement, which is located here.

Phone of counselee, parent or guardian

Country

(###)

###

####

Email Address of counselee, parent or guardian

Address of Counselee

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate of Counselee

YYYY

Gender of counselee

If you selected "Other" or if there are aspects of your gender you need to explain that will be relevant to your counseling, please do so here.

Are you under the age of 18 or under someone's legal guardianship?

Yes

If you checked "yes" then please write the name(s) of your parent(s) or legal guardian(s) and explain that one of them will need to sign this form.

CHILDHOOD FAMILY HISTORY of COUNSELEE

Who Raised You?

If you checked "Other" please explain here:

How many full brothers and sisters do you have?

How many step brothers and sisters do you have?

How many half brothers and sisters do you have?

Please share any important information about your childhood family (happy home, domestic or sexual abuse, frequent moves, parents fought a lot, divorce, boarding school, etc.)

COUNSELEE RELATIONSHIP & FAMILY INFORMATION

What is your current relationship status?

If you checked "Other" and would like to explain, please do so here:

If married, when were you married?

YYYY

Name of Significant Other (Spouse, fiance, boyfriend or girlfriend)

First Name

Last Name

Status of Significant Other

Significant Other's Phone

Country

(###)

###

####

Significant Other's Occupation

Significant Other's Education (Years)

Significant Other's Religion

Is your significant other born-again?

If needed, is your significant other willing to participate in counseling?

If married, have you ever been separated?

If you were separated, please explain why you separated and why you got back together. If you are currently separated, please explain why. Please also provide the dates or length of time of the separation.

If married, how old were you when you married?

If married, how old was your spouse when you married?

If married, how long did you know your spouse before marriage? If not married, how long have you known each other?

How long did you steadily date before engagement? Or, how long have you been steadily dating?

If married, how long were you engaged before you married?

Please provide brief information about previous marriages, if any:

If you have children, please list their names, ages, and life status (high school, college, etc.)

How much conflict is in your relationship?

If there is conflict, what is it usually regarding?

How happy would you say you are in your relationship?

How commited are you in your relationship?

Why?

If you desire counseling regarding your relationship, what do you want help with?

If married, engaged or living together, have either of you ever cheated, or do you suspect this? If so, please explain if the cheating relationship is ongoing, if the other person knows, etc.

COUNSELEE HEALTH INFORMATION

Have you had any recent weight changes for reasons other than dieting?

If so, how much weight have you gained or lost?

If you are not sleeping at least eight hours per night, please explain why.

Date of last medical exam:

YYYY

Rate your health:

Please explain your health rating:

Are you currently taking any prescribed medications?

If you are taking prescription meds, please list all medicines and the condition the medicine is treating:

If you currently are using, or sometimes are using any non-prescription drugs or herbs, please list them and the reason why:

Describe your alcohol consumption:

Describe you caffeine consumption:

Do you currently take any painkillers? If so, what kind, how much any why?

If you have ever had a severe emotional upset? If so, please describe what happened and whether or not it is ongoing.

If you have any disabilities or illnesses, please describe:

COUNSELEE RELIGIOUS BACKGROUND

Denominational preference, if any:

If you attend church, please provide the name and city of the church:

On average, how many times do you attend church a month?

What church did you attend in childhood?

Were you baptised as an infant?

Do you consider yourself a religious person?

Do you believe in God?

How often do you pray to God?

Are you born again?

How often do you read the Bible?

Have you had believer's baptism (baptism afer trusting in Jesus)?

If you are married, how often do you have family devotions?

Explain recent changes in your religious life, if any:

COUNSELEE OCCUPATION

Please describe your current occupation:

Please describe your level of contentment with your current occupation.

What are some occupations you have had in the past?

What would your ideal career be, and why?

COUNSELEE EDUCATION

Please describe your education (high school, college, grad school, etc)

If you are currently in school, where are you attending, and what degree or certification are you working towards?

If you have further educational aspirations, please describe them:

COUNSELEE INTERESTS

Please briefly describe your hobbies favorite interests or activities.

WHY YOU (THE CONSELEE ) DESIRE COUNSELING

What are the primary things you want your counselor to help you resolve, understand, or achieve?

What in particular are you hoping your counselor will do to help you achieve it?

What have you personally done to try to achieve this?

As you see yourself, what kind of a person are you?

Please describe your current emotional state.

Please describe your current spiritual state.

If someone else will be receiving counseling along with you, or observing the counseling process, is there anything you have shared on this form that you do not want that person to know? Please answer "Yes" or "No." If your answer is "Yes" please tell us that person's name, and what you do not want to be shared with that person here.

If you were referred to us by a pastor, doctor, or other professional, do you want us to share your case information with that person?

Please briefly specify information you want withheld:

LEGAL STUFF:

Have you read and understood the information on the PeaceBrooke.org website, including the qualifications of your counselor, PeaceBrooke's beliefs, and PeaceBrooke's approach to Biblical counseling?

Yes

Please read PeaceBrooke's Terms, Conditions, and Privacy Notice.

Have you read PeaceBrooke's Terms, Conditions, and Privacy Notice in its entirety and fully understood it, including the conditions for counseling set forth therein, given your consent to them, and agreed to abide by them?

Yes

Electronic Signature of Adult Counselee, or Parent or Legal Guardian of Counselee

The information I have entered is true. I understand and agree to abide by PeaceBrooke's Terms and Conditions, and give my consent to their Privacy Notice. I have also read the information presented on the PeaceBrooke.org website, and request and fully agree to receiving Biblical Counseling under the terms and conditions presented therein. I am typing my name below to serve as my legal signature.

Signature Date

YYYY

Intake Form

New Client Data Inventory Form