Healing Thine Hearts Family Counseling
INTAKE/DISCOVERY
INTERVIEW
(We engage in only Biblical Counseling and Restoration. Healing Thine Hearts is operated by Certified Therapists
(Licensed and Ordained Ministers.)
NAME: _________________________________________________ DATE: ______________________________
ADDRESS: _________________________________________________ AGE: ____________________________
CITY: ______________________________ STATE: _________ ZIP: ___________________________________
PHONE #’S: (HOME) _____________________________ (WORK) ____________________________________
(CELL) ____________________________________ EMAIL ___________________________________________
MARITAL STATUS: ________________ NO. YEARS: __________ SPOUSE: __________________________
NAMES OF CHILDREN / STEPCHILDREN
M/F
AGE
RESIDENCE
__________________________________________
____
_____
_______________________
__________________________________________
____
_____
_______________________
HOW LONG HAVE YOU BEEN SAVED? YRS. ____ MO. ___ WKS. ___
HAVE YOU BEEN WATER BAPTIZED SINCE YOUR SALVATION? YES ___ NO ___
HAVE YOU RECEIVED THE BAPTISM OF THE HOLY SPIRIT COMBINED WITH YOUR PRAYER LANGUAGE
(DO YOU SPEAK IN TONGUES)? YES ___ NO ___ NOT SURE___
IF SO, WHEN DID YOU RECEIVE YOUR PRAYER LANGUAGE? _______________
AND HOW OFTEN DO YOU USE IT? __________________
WHAT CHURCH ARE YOU A MEMBER OF _____________________________________________________
HOW LONG? ______________________
PLEASE CIRCLE AREAS OF CONCERNS:
SPIRITUAL
SEXUAL-ABUSE/NEGLECT
CHILDREN / FAMILY
EMOTIONAL
COMMUNICATION
ALCOHOL / DRUGS
MENTAL-ABUSE
FINANCIAL
OTHER_____________________
HOW LONG HAS THIS PROBLEM OCCURRED? __________________________________________________
ELABORATE ON ITEMS THAT YOU CIRCLED
ABOVE______________________________________________________________________________________
_____________________________________________________________________________________________
LIST AREAS WHERE YOU HAVE BEEN IN CONTRADICTION TO KINGDOM LIVING (AGREEMENT WITH SIN,
OR PAST WEAKNESSES, ETC.). THESE ARE THE THINGS FOR WHICH YOU NEED TO ASK FORGIVENESS.
______________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
HAVE YOU EVER SOUGHT COUNSEL PRIOR TO THIS TIME?
YES _______ NO ________ IF YES, FOR WHAT REASON? _________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
WITH WHOM-WHERE?
_____________________________________________________________________________________________
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 1
Healing Thine Hearts Family Counseling
INTAKE/DISCOVERY
INTERVIEW
(page 2)
ARE YOU WILLING TO TAKE PERSONAL RESPONSIBILITY FOR THE SOLUTION TO THIS PROBLEM?
YES _______ NO _______ IF NO, PLEASE EXPLAIN: ______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
In order for this ministry to effectively assist you there are certain guidelines that must be adhered to and agreed upon before
ministry can be given. Our desire is not to grieve the Holy Spirit by making rules; however, we believe that all things must be
done in order. Part of discipleship is obedience, sacrifice, and commitment. These three things are required in order to obtain
the elements of freedom and release you desire. The following guidelines are based upon this premise:
1.
If you are a member of a church, we request that you attend services together at least once a week.
2.
You are here to receive consultation and are expected to complete all assignments. Negligence in this area will eventually
cause sessions to be terminated, as progress will be impeded.
3.
Financial responsibility – Fees are paid on a per hour basis and payment required upon completion of each session. Fees
received are to cover counseling and ministry time as well as continued education for counseling and Ministry. In
conjunction, supportive and love offerings are welcomed to further promote strong marriage relationships and the growth of
our ministries’ effort to build healthier families.
4.
Office sessions =
$100.00 per hour. (single, couples, or family)
Telephone sessions = $25.00 per 15 minute telephone segment
$50.00 per 30 minute telephone session
$100.00 per 60 minute telephone session
**Credit Card: MC___ VISA___ AMEX___ #_____________________________Exp.Date__________mmyy CRN# _ _ _
Street Address________________________________________ City______________________ State_____ ZIP_______
**Please make all checks payable to Healing Thine Hearts Ministries
5.
In order to fulfill the needs of those who are seeking assistance it is of the utmost importance that all appointments be kept
unless it is unavoidable. Twenty-four hour cancellation in advance is greatly appreciated. Three canceled appointments in a
row will be interpreted as a lack of commitment in this area and sessions will be terminated until an agreed-upon schedule
can be reached.
6.
Your counseling session is a private matter between you, the Lord and your counselor. Therefore it is important that you
order your conversation and use discernment in the things you expose to friends, family and other peers. All counsel given
by Healing Thine Hearts is subject to pastoral supervision and any questions regarding your sessions should be directed
toward those whom you trust in positions of responsibility. We encourage you to share with those you feel will benefit from
your progress and anything you feel of significance.
-------------------------------------------------------------------------------------------------------------------------------------------------------
7.
Domestic violence and child abuse issues will be reported to the appropriate authorities, as required by law. (i.e.
Child Protective Services and/or Police Department)
I understand these requirements and agree to abide by them. I further understand that if I am under 18 years of age, I am
required to provide parental signature for counseling.
____________________________________
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 2
Healing Thine Hearts Family Counseling
PERSONAL DATA INVENTORY
Please complete this inventory carefully and thoroughly, and then return this Inventory via email or bring it with you to your first session:
Healing Thine Hearts Ministries
6300 Stonewood Dr. Suite 106-A
Plano, TX 75024
PERSONAL INFORMATION
Birth Date______/________/________
Age______ Sex_________ Height_________ Referred for Counseling by_____________________________
Marital Status (mark all that apply)
□ Never Married □ Single □ Going Steady □ Engaged □ Now Married ____year(s)
□ Now Separated ____month(s) □ Divorced ____time(s) □ Widowed
Home Phone(____)_______________ Work Phone(____)_______________ Mobile(____)__________________
Email Address___________________________ Education (last level completed)_____________________
Other Training (list type and years)__________________________________________________________
Occupation_____________________ Employer___________________ Position________________ Yrs______
In case of an emergency, please contact: Name_________________________________________________
Phone Number(___)__________________________
MARRIAGE AND FAMILY
Information about Your Spouse (If never married, check here □ and omit this section)
Spouse’s Name__________________________________________ Spouse’s Birth Date_____/_____/_____
Spouse’s Address_____________________________City__________________State_____Zip_____________
Spouse’s Age______ Spouse’s Home Phone(____)__________________
Spouse’s Work Phone(___)________________ Spouse’s Mobile(___)_________________
Spouse’s Email Address___________________________________________________
Spouse’s Education (last level completed)__________ Spouse’s Occupation_____________________
Spouse’s Religious Background________________________________________________________________
Your ages when married: You _____ Spouse _____
Date of Marriage____/____/____ Length of Steady Dating______ Length of Engagement______
Give a brief statement of circumstances of meeting and dating_________________________________
______________________________________________________________________________________________
Has your spouse previously been married? □ Yes □ No # of times_________
Have you ever been separated? □ Yes □ No When? from _________ to __________
Is your spouse willing to come for counseling? □ Yes □ No □ Uncertain
Rate your marriage: □ Unhappy □ Average □ Happy □ Very Happy
Give brief information about any of your previous marriages___________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Healing Thine Hearts Family Counseling
Information about Your Children:
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 3
Name
Age
Sex
(M/F)
Living?
Education Step-Child?
(in years)
Married? By Previous
Marriage?
_________________ ___
___
□Y □N _____
□Y □N □Y □N □Y □N
_________________ ___
___
□Y □N _____
□Y □N □Y □N □Y □N
_________________ ___
___
□Y □N _____
□Y □N □Y □N □Y □N
_________________ ___
___
□Y □N _____
□Y □N □Y □N □Y □N
_________________ ___
___
□Y □N _____
□Y □N □Y □N □Y □N
Information about Your Parents:
If you were reared by anyone other than your own parents, briefly explain:____________________
______________________________________________________________________________________________
Is your father still living? □ Yes □ No
Does he live nearby? □ Yes □ No
Where? ____________________
Father’s Religious Affiliation__________________ Father’s Occupation________________________
Describe your relationship with your father___________________________________________________
______________________________________________________________________________________________
Is your mother still living? □ Yes □ No
Does she live nearby? □ Yes □ No
Where? _____________________
Mother’s Religious Affiliation_________________ Mother’s Occupation_________________________
Describe your relationship with your mother___________________________________________________
______________________________________________________________________________________________
Have your parents divorced? □ Yes □ No
Rate your parent’s marriage: □ Unhappy
□ Average
□ Happy
□ Very Happy
Information about Your Siblings:
Number of older brothers____ older sisters____ younger brothers____ younger sisters____
Rate your childhood: □ Unhappy
□ Average
□ Happy
□ Very Happy
Have there been any deaths in your family during the last year? □ Yes □ No (if yes, please
describe) ____________________________________________________________________________________
LEGAL
If you have talked with an attorney about your situation, or intend to, please provide:
Attorney’s Name_____________________ Firm______________________________________________
Address_______________________________________________ Phone____________________________
Has a legal action been filed or is one likely to be filed in this situation? □ Yes □ No
If yes, give dates and describe action_________________________________________________
If you have received advice or counsel from anyone else regarding your situation, please list their name(s) and their
relationship to you_________________________________________________________
Healing Thine Hearts Family Counseling
HEALTH HISTORY
Rate your health: □ Very Good □ Good □ Average □ Declining □ Other_______________________
Do you have any chronic conditions? □ Yes □ No What?________________________________________
List significant illnesses, injuries or handicaps_____________________________________________
Your approximate weight _________lbs.
Weight changes recently? Lost_____ Gained______
Date of last medical exam____________ Results of examination:_________________________________
Physician’s Name_________________________________________________Phone(___)__________________
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 4
Address__________________________________City__________________State_________Zip______________
Are you currently taking any prescription or over-the-counter medications? □ Yes □ No
If yes, please list name(s) and dosage(s)_____________________________________________________
Have you ever used drugs for other than medical purposes? □ Yes □ No
If yes, please explain________________________________________________________________________
Have you ever been arrested? □ Yes □ No If yes, please explain circumstances________________
______________________________________________________________________________________________
Do you drink alcoholic beverages? □ Yes □ No If yes, how frequently and how much?
______________________________________________________________________________________________
Do you drink coffee? □ Yes □ No How frequently and how much?________________________________
Other caffeinated drinks? □ Yes □ No How frequently and how much?___________________________
Do you use tobacco? □ Yes □ No What?____________________ Frequency?_________________________
Have you ever had interpersonal problems on the job? □ Yes □ No If yes, please explain
______________________________________________________________________________________________
Have you ever had a severe emotional upset? □ Yes □ No If yes, please explain_______________
______________________________________________________________________________________________
Have you ever seen a psychiatrist or counselor? □ Yes □ No If yes, please explain___________
______________________________________________________________________________________________
List counselor/therapist and dates____________________________________________________________
What was the outcome?_________________________________________________________________________
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric or other
medical records?
□ Yes □ No
Have you ever felt people were watching you? □ Yes □ No
Do people’s faces ever seem to be distorted?
□ Yes □ No
Do colors sometimes seem… □ Too bright? □ Too dull?
Are you sometimes unable to judge distance? □ Yes □ No
Have you ever had hallucinations?
□ Yes □ No
Is your hearing exceptionally good?
□ Yes □ No
Do you have problems sleeping?
□ Yes □ No
How many hours of sleep do you normally get each night? _______________________________
Healing Thine Hearts Family Counseling
SPIRITUAL BACKGROUND
Religion: □ None □ Christian □ Jewish □ Muslim □Agnostic □ Other________________________
Denominational preference_____________________________________________________________________
Church attending____________________________________________________ Member?
□ Yes □No
Church Address________________________________________________________________________________
Phone(___)_______________________________ Pastor’s Name______________________________________
Church attendance per month (circle) 0 1 2 3 4 5 6 7 8+
Please describe your religious upbringing?____________________________________________________
______________________________________________________________________________________________
Do you believe in God? □ Yes □ No □ Uncertain Why?_________________________________________
______________________________________________________________________________________________
How often do you pray to God? □ Daily □ Weekly □ Occasionally □ Never
How often do you read or study the Bible? □ Daily □ Weekly □ Occasionally □ Never
Would you say you are a Christian or still in the process of becoming a Christian?____________
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 5
______________________________________________________________________________________________
Do you believe that when you die, you will be with God eternally? □ Yes □ No □ Uncertain
Why?__________________________________________________________________________________________
______________________________________________________________________________________________
Have you been baptized? □ Yes □ No
Explain any recent significant changes in your religious life_________________________________
______________________________________________________________________________________________
What is your opinion of the Bible?
□ I don’t know enough about the Bible to have an opinion.
□ It is a book that contains helpful principles that I am free to follow or disregard as I
think best.
□ It is a book that was inspired by God and that contains helpful principles and
instructions I should follow unless I believe there is a good reason to do otherwise.
□ It is a book that was inspired by God and that contains helpful principles, instructions,
and commands that I should follow regardless of my feelings or preferences.
□ Other:_____________________________________________________________________________________
Who, if anyone, has the most influence on your religious or spiritual life? (please list their names and their
relationship to you)__________________________________________________________
WOMEN ONLY
Have you had any menstrual difficulties? □ Yes □ No If yes, please explain__________________
______________________________________________________________________________________________
Is your husband in favor of your coming for counseling? □ Yes □ No
If no, please explain_________________________________________________________________________
BRIEFLY ANSWER THE FOLLOWING QUESTIONS
(Before you begin, read all 6 questions so that you can see how to organize your answers)
1. What is the main problem as you see it (what brings you here)?
2. What have you done to try to resolve this problem or dispute?
3. What issues or questions do you want to have resolved or answered?
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
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4. What do you want us to do? (What are your hopes and expectations in coming here?)
5. As you see yourself, what kind of person are you? Describe yourself.
6. Is there any other information we should know?
Abortion
Adultery
Anger
Anxiety (worry)
Apathy
Appetite
Bitterness (resentment)
Change in lifestyle
Children
Communication
Conflict (fights)
Deception
Decision making
Dating/courtship
Depression
PROBLEM CHECK LIST
(Please check all areas of concern or struggle)
Divorce
Loneliness
Drug abuse
Lust
Drunkenness
Marriage
Eating habits
Memory
Envy (jealousy)
Menopause
Fear
Moodiness
Finances
Past memories
Grief
Perfectionism
Guilt
Rebellion
Health
Sex
Homosexuality
Singleness
Impotence
Sleep
Infertility
Wife abuse
In-laws
_____________
Laziness
_____________
POSITIVE TRAITS INVENTORY
Matthew 7:1-5
Rate yourself on each of the following traits. Before each word, put the number from the rating scale which most
accurately describes you.
Rating scale: 0 = never
1 = seldom
2 = sometimes 3 = often
4 = usually
_____ Loving
_____ Honest
_____ Sensitive
_____ Patient
_____ Considerate
_____ Persistent
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 7
_____ Good father/mother
_____ Works hard
_____ Humble
_____ Keeps his/her word
_____ Dependable
_____ Does not take advantage of others
_____ Does not use people
_____ Not an opportunist (waiting for a lucky break)
_____ Plans ahead
_____ Knows where he/she is going
_____ Fair
_____ Consistent
_____ Perseveres
_____ Admits it when he/she is wrong
_____ Teachable
_____ Objective
_____ Compassionate
_____ Cooperative
_____ Neat
_____ Punctual
_____ Disciplined
_____ Resourceful
_____ Sincere
_____ Courteous
_____ Creative
_____ Decisive
_____ Efficient
_____ Flexible
_____ Forgiving
_____ Generous
_____ Frugal
_____ Appreciative
_____ Hospitable
_____ Diligent
_____ Discerning
_____ Enthusiastic
_____ Courageous
_____ Conscientious
NEGATIVE TRAITS INVENTORY
Matthew 7:1-5
Rate yourself on each of the following traits. Before each word, put the number from the rating scale which most accurately describes you.
Rating scale: 0 = never
_____ Argumentative
_____ Arrogant/Proud
_____ Belittles others
_____ Bitter
_____ Blame-shifts
_____ Blows up
_____ Secretive
_____ Brutal/Harsh/Cruel
_____ Clams up
_____ Cliquish
_____ Closed minded
_____ Complaining
_____ Conceited
_____ Greedy
_____ Sarcastic
_____ Crabby
_____ Critical
_____ Untrustworthy
_____ Deceitful
_____ Demanding
_____ Disobedient
_____ Domineering
_____ Irresponsible
_____ Jealous
_____ Judgmental
_____ Lazy
_____ Unloving
_____ Lying
_____ Resentful
1 = seldom
2 = sometimes 3 = often
4 = usually
_____ Embarrassing
_____ Fussy
_____ Gets the last word
_____ Rude
_____ Gossipy
_____ Greedy
_____ Un-submissive
_____ Hateful
_____ Holier-than-thou
_____ Unreasonable
_____ Ignores counsel
_____ Impatient
_____ Impractical
_____ Inconsiderate
_____ Inconsistent
_____ Indecisive
_____ Indifferent
_____ Inflexible
_____ Insensitive
_____ Reckless
_____ Insulting
_____ Interrupting
_____ Selfish
_____ Self-willed
_____ Shouting
_____ Ungrateful
_____ Snoopy
_____ Makes Excuses
_____ Wasteful
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 8
_____ Manipulating
_____ Meddling
_____ Mischievous
_____ Nagging
_____ Never Satisfied
_____ Overambitious
_____ Rebellious
_____ Overly independent
_____ Perfectionist
_____ Wishy-washy
_____ Picky
_____ Possessive
_____ Procrastinator
_____ Unforgiving
_____ Stingy
_____ Stubborn
_____ Suspicious
_____ Unfair
_____ Temper Outbursts
_____ Easily offended
_____ Thoughtless
_____ Touchy
_____ Puts off dealing with problems
_____ Unbelieving
_____ Pushy
_____ Uncooperative
Gen 2:24 Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh. Gen 2:25 And they were
both naked, the man and his wife, and were not ashamed.
Page 9