Gender at Birth * Required
May we leave messages here? * Required
Past or Current Relationship Issuses
Has a signifcant person or family member entered or left your life in the last 90 days?
Describe your current friendships
Describe your relationship with your boss and coworkers
Was your father present in your life growing up? * Required
Was your mother present in your life growing up? * Required
Was someone else involved in raising you? * Required
Please describe if the answer was no or sometimes to any of the above:
Do you have any children? * Required
If yes, please describe their ages and your relationship with them:
What do you admire most about your father?
What characteristics about your father would you least like to adopt?
What do you admire most about your mother?
What characteristics about your mother would you least like to adopt?
Describe any mental or physical issues that keep you from being employed or maintaining employment:
Describe your educational background and relationship with school growing up:
Describe your experience with church in general?
What role if any did church/religion play in your childhood?
Have you been baptized? * Required
If applicable describe your spouse’s church background and attendance:
Describe your prayer life and what ou believe prayer does:
Is Jesus Christ your Lord and Saviour? * Required
What does it mean for Jesus to be your Lord and Saviour?
How would you describe God?
How would you describe the person and role of Holy Spirit?
How do you think God would describe you and His love for you?
Does this line up with how you feel about yourself?
If Applicable, what has changed in your behaviour, thinking, and overall life experiece since you became a Christian?
What is the great commission?
How often do you read your bible? If applicable, do you read the Bible and pray as a family? Please describe any recent changes in your spiritual life:
Please describe any changes you would like us to help you with in your spiritual life:
Have you had counseling before? * Required
Have you seen a psychiatrist before? * Required
Have you participated in any of these therapies?
If you answered yes to any of the above, please describe your experience:
Please describe any health issues :
Please list any medications, what they are for, and how long you have been taking them:
Have you used drugs for anything other than medicinal purposes? * Required
Do you drink alcohol more than once a week? * Required
Would you or someone you know say you currently or have ever had problems with other addictions, like gambling, pornography, or shopping?
Describe any changes in eating or appetite:
Describe your exercise routine:
Describe non-working hours per week spent on: television, social media, computer, hobbies:
If you feel comfortable doing so, please briefly describe any traumatic events in your life. Note: This may unintentionally trigger some overwhelming emotions, please refer to our resource page at sacredtreeministries.com, dial or text 988 for the crisis help line, or message us if you you begin to feel extreme emotions following this question or any question on this form
Which of the following words best describe your home of origin (check all that apply): * Required
How would you describe your family/home environment growing up?
In order to understand me:
My ambition in life is to:
What really hurts me is when:
I get nervous when:
I wish I could lose my fear of:
What I wish I could change about myself:
My best childhood memory:
My worst childhood memory:
My father is/was:
My mother is/was:
My biggest regret is:
My greatest achievement is:
My role in my current family is:
For refuge/rest I turn to:
When life gets too hard I:
To be happy I need:
I would do anything for:
I often wonder why:
It embarrasses me to:
I cannot decide:
I understand that change takes commitment. I think I need to commit to changing this about myself, my lifestyle, and/or my habits:
Other than counseling, what help are you seeking?
Who referred you to Muck & Mire Biblical Foundations Counseling?
Please describe any family history (the family you grew up in), which might be pertinent to the concerns that you bring to counseling (your relationship with your parents, their relationship with each other, significant losses or events):
What are your expectations in coming here?
What, if any, are your concerns about coming to counseling?
What do you believe you will have to change to see the progress you desire?
Is there any other information we should know?
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Thanks for submitting!
I will review your answers and schedule a time to discuss them in session. If this form caused any unexpected feelings to emerge or you need to discuss them before the first session, please reach out or check out our resource page for emotional relaxation exercises.
- Susanne Poté
