Client FormsThis page is for new and current client forms. Please contact us with any questions or concerns. New Client Intake Form New Client Intake Form Name * First Name Last Name Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Marital Status * Single Married Divorced Separated Widowed Have you had professional counseling before? * Yes No If yes, please describe. * Have you received Jesus Christ as your Savior? * Do you attend church? If so, where? * Why are you are seeking Biblical Counseling? * What is the extent of your need? * Mild Moderate Severe Please describe your main problems, areas of concern, or needs. * Please describe any life-altering events you've experienced within the last 2 years. * Would you like your appointments to be in-person or online? * In-Person Online How did you hear about Restoration Biblical Counseling? * Friend or Family Member Church Social Media Google Search Other Emergency Contact * (Name, Relationship, and Phone Number) Thank you for submitting your form! We will be in touch soon. Client Evaluation Form Client Evaluation Form Name * First Name Last Name Email * My appointments were mainly * In-person Online How long were you seen by someone at Restoration Biblical Counseling? * Less than 6 months 6 months to 1 year More than 1 year but less than 2 years More than 2 years My privacy was respected while a client at Restoration Biblical Counseling. * Strongly Disagree Disagree Neutral Agree Strongly Agree The staff at Restoration Biblical Counseling was very professional. * Strongly Disagree Disagree Neutral Agree Strongly Agree During my sessions, I felt heard and cared for. * Strongly Disagree Disagree Neutral Agree Strongly Agree Scripture and Biblical Principles were used to work through whatever issue I was facing. * Strongly Disagree Disagree Neutral Agree Strongly Agree The counsel I received was effective to deal with the issues I was facing. * Strongly Disagree Disagree Neutral Agree Strongly Agree I would recommend Restoration Biblical Counseling to a friend or family member. * Strongly Disagree Disagree Neutral Agree Strongly Agree We always welcome your thoughts! Please provide us with suggestions on how to better serve others in the future! * If you are willing to provide a testimonial, we would greatly appreciate it. To protect your privacy, only your first name will appear in any quotes. Is there anything else you want us to know? Thank you!
