Center for Biblical Coaching

Personal Data Information (Pre-marital)

Identification Data

1. Your Name
2. Sex
3. M F

Birthdate

1. Marital Status
2. Single Separated Divorced Widowed
3. Email
4. Address
5. City
6. State
7. Zip
8. Occupation
9. Phone
10. Education (last year completed)
11. Other training (list type and years)
12. Referred here by

Health Information

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

Religious Background

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

Personality Information

1. Have you ever had any coaching, psychotherapy or counseling before?
2. Yes No
3. If yes, explain
4. Describe your personality
5. Have you ever felt people were watching you?
6. Yes No
7. Do people's faces ever seem distorted?
8. Yes No
9. Do you ever have difficulty distinguishing faces?
10. Yes No
11. Do colors ever seem too bright or to dull?
12. Yes No
13. Are you sometimes unable to judge distance?
14. Yes No
15. Have you ever had hallucinations?
16. Yes No
17. Are you afraid of being in closed in spaces?
18. Yes No
19. Is your hearing exceptionally good?
20. Yes No
21. Do you have problems sleeping?
22. Yes No

Marriage and Family Information

1. Name of fiance
2. Address
3. City
4. State
5. Zip
6. Phone
7. Occupation
8. Your fiance's age
9. Your fiance's religion
10. Have you ever been broken up?
11. Yes No
12. If yes, when?
13. Why did you get back together?
14. Date of wedding
15. Your ages when you marry
16. How long have you dated steadily?
17. Give brief information about any previous marriages
18. Please list all children and indicate if any were from previous relationships
19. If you were reared by anyone other than your parents, briefly explain
20. How many older brothers do you have?
21. How many older sisters do you have?
22. How many younger brothers do you have?
23. How many younger sisters do you have?

General Questionnaire

1. What is/are the main challenges for your marriage, as you see it?
2. What have you done about it?
3. What do you fear? What do you tend to worry about?
4. What can a coach do? What are your expectations in having a coach?
5. Describe your motivation for wanting pre-marital coaching.
6. What are your three strongest talents? (Please explain)
7. What are your three weakest areas? (Please explain)
8. Are you currently sexually active? Yes No
9. If yes, are you willing to commit to abstaining from sex until the wedding? Yes No
10. Please write any other pertinent information you'd like your coach to know

 

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