Pre-Counseling Questionnaire

Please fill out this pre-counseling questionnaire prior to your first counseling session at Petra Bozeman.

First Name

Last Name

Phone Number

Date of birth

Family History

1) Describe the atmosphere and relationships you experienced during your childhood. Information about closeness to the family, who exerted authority (dad or mom), the role of religion, the extended family, education, and health. What kind of family did you grow up in?

2) Please list name and ages of your parents. Include step parents, also, if applicable. If any have died, please record the year and the person’s age at death.

3) Please list the names and ages of brothers and sisters. If any have died, please record the year of death and the person’s age at death.

4) If married, please give name and age of your spouse and the date of your marriage. If you have been married before, please write the name of your former spouse(s) and the date(s) of that (those) marriage(s).

5) Briefly describe your marital relationship(s).

6) Did you have premarital counseling? How long? How much? What did it consist of?

7) Have you truly left your father and mother (emotionally, spiritually, financially, and mentally)? (Genesis 2:28-29) Why or why not?

8) Please give the names and ages of all children and stepchildren, whether or not they are living at home.

Note: In the following questions, the term “family” refers to extended family (parents, stepparents, brothers, sisters, aunts, uncles, children, etc)

9) Do you or anyone in your family have a history of depression or other illness? Have you or any member of your family member ever attempted suicide, or been hospitalized for a mental illness? If so, who and when?

10) Have you or any family member ever had a problem misusing alcohol or drugs? Who and for how long? Is there a current problem?

11) Is there any other relevant medical history for yourself of your extended family to note?

Education / Work

12) How did you do in school?

13) Current Job and jobs held previous to current one.

Spiritual

14) What is your spiritual background? Include involvement in church during upbringing, past churches attended, denomination, etc. Is there any history of occult practices in your family?

15) If you are a follower of Christ, what is your testimony of salvation? When did you come to Christ? Who led you to Christ?

16) Have you ever done a timeline of your life? With key people and events?

Counseling Concerns

17) What is the main current problem in your personal life and / or marriage that you would like to see God redeem?

18) Please list the names of anyone you have seen for counseling in the past, or anyone you currently work with. Please write the year / time frame in which you worked with them. Include counselors, psychologists, psychiatrists, pastors.)

19) What goals do you hope to accomplish through counseling meetings?

20) Additional comments

Signature

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