Center for Biblical Coaching

Personal Data Information (Married)

General Information

1. Your NameRequired
2. Sex M F
3. BirthdateRequired
4. Marital Status Married Separated Divorced Widowed
5. Email
6. AddressRequired
7. CityRequired
8. StateRequired
9. ZipRequired
10. OccupationRequired
11. PhoneRequired
12. Education (last year completed)Required
13. Other training (list type and years)
14. Referred here byRequired

Health Information

1. Rate your health Very good Good Average Declining Required
2. Have you had any significant weight changes recently? Yes No Required
3. List all important present or past illnesses, injuries or handicaps
4. Date of last medical examination
5. Report from that examination
6. Are you presently taking medication? Yes No Required
7. If yes, what medication?
8. Have you ever had a severe emotional upset? Yes No Required
9. If yes, explain

Religious Background

1. Denominational preferenceRequired
2. Are you a member? Yes No Required
3. Church attendance per month 0 1 2 3 4 5 6 7 8 9 10+ Required
4. Do you consider yourself a religious person? Yes No Uncertain Required
5. Do you believe in God? Yes No Uncertain Required
6. Do you pray to God? Often Occasionally Never Required
7. Are you saved? Yes No Uncertain Required
8. How much do you read the Bible? Often Occasionally Never Required
9. Do you have regular family devotions? Yes No Required
10. Explain recent changes in your religious life, if any

Personality Information

1. Have you ever had any coaching, psychotherapy or counseling before? Yes No Required
2. If yes, explain
3. Describe your personalityRequired
4. Have you ever felt people were watching you? Yes No Required
5. Do people's faces ever seem distorted? Yes No Required
6. Do you ever have difficulty distinguishing faces? Yes No Required
7. Do colors ever seem too bright or to dull? Yes No Required
8. Are you sometimes unable to judge distance? Yes No Required
9. Have you ever had hallucinations? Yes No Required
10. Are you afraid of being in closed in spaces? Yes No Required
11. Do you have problems sleeping? Yes No Required

Marriage and Family Information

1. Name of spouseRequired
2. Address (if different than yours)
3. Phone
4. Occupation
5. Spouse's religionRequired
6. Is your spouse willing to come for coaching? Yes No Required
7. Have you ever been separated? Yes No Required
8. If yes, when?
9. Has either of you ever filed for divorce? Yes No Required
10. If yes, when?
11. Date of marriage
12. Your ages when married
13. How long did you know your spouse before marriage?Required
14. How long were you engaged?Required
15. What would you say are the main reasons you got married?Required
16. Give brief information about any previous marriages
17. Please list all children and indicate if any were from previous marriages/relationships
18. If you were reared by anyone other than your parents, briefly explain
19. How many older brothers do you have?
20. How many older sisters do you have?
21. How many younger brothers do you have?
22. How many younger sisters do you have?

General Questionnaire

1. What is/are the main problems, as you see it? Required
2. What have you done about it?Required
3. What do you fear? What do you tend to worry about?Required
4. What can a coach do? What are your expectations in having a coach?Required
5. Describe your motivation for wanting changeRequired
6. What are your three strongest talents? (Please explain)Required
7. What are your three weakest areas? (Please explain)Required
8. In writing your epitaph, what would you want people to remember about you?Required
9. What are you doing in your life now that will last forever?Required
10. Please write any other pertinent information you'd like your coach to know

 

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