* = Required Information
Biblical Counseling Intake Form

(Only include telephone numbers that we have permission to call and/or leave messages)

Single Married Widowed Separated
Divorced
Family Data

Yes No
Child's Name Age Gender Does child live at home? Check if child is from a previous marriage
Religious Data

Yes No
Rarely Occassionally Always
Active
Shy
Excitable
Serious
Leader
Easy Going
Guilt
Loss of Love
Sexual Concerns
Relationship w/Children
Ambitious
Hardworking
Imaginative
Good Natured
Quiet
Lonely
Adultery
Suicidal
Loss of Respect
Frustrated
Self-Confident
Impatient
Calm
Introvert
Bossy
Bereaved
Frigid
Loss of Faith
Religious Fears
Disappointed
Persistent
Moody
Controlling
Extrovert
Sensitive
Fearful
Homosexual
Loss of Meaning
Religious Doubts
Fear of Failure
Nervous
Depressed
Submissive
Likeable
Self-Conscience
Self Doubt
Angry
Marriage Problems
Relationship w/Parents
Addictions
COUNSELING FEE'S AND CANCELLATION POLICIES:

We at "No Longer Bound" does not charge an extensive fee for counseling; however, we do ask that you sow a seed into the ministry. We give our clients the opportunity to choose 45 minute intervals.

In the event you are unable to keep an appointment, a 24 hour advance notice is required with the exception for emergencies such as death, illness or an accident. If you do not call to cancel and/or do not show, you will not be considered a priority in future appointments.

ACKNOWLEDGEMENT

"No Longer Bound" is a counseling center that provides deliverance, healing and wholeness to the soul through avenues of biblical truths, prophetic insight and deliverance sessions.

Please acknowledge that you understand each counseling and bullet point regarding the counseling center through signing below:


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