VCLi BCN Questionnaire - L Southwick
Biographical Information
First Name:
Last Name:
Email:
City and State
Country Code and Cell Number
Occupation
Birthdate (MM/DD/YYYY)
Gender
Age
I was referred to VCLi Biblical Counseling by:
My relationship to my referrer is:
Family Information
If you have had previous marriage(s) please give a short overview (If no enter N/A)
Marital Status
Name of Spouse (if not applicable, enter N/A)
Does your Spouse know you are coming for counseling?
Is your Spouse willing to come for counseling?
Have you ever been Separated?
If Yes, when were you separated?
From to
Personal History
Have you had or do you deal with severe emotional struggles?
List your child(ren)'s name and age (if not applicable, mark N/A)
Have you ever had therapy or counseling before?
If you have had counseling/therapy, list the therapist(s) and/or counselor(s) names and dates you saw them.
What were the results of your counseling/therapy?
Have you ever been arrested, and if Yes, what was the reason?
Health Information
Rate your health:
How many hours sleep do you get in a normal night?
Do you have any chronic medical conditions? If yes, please list and describe below.
Have you used any illegal or excessive prescription drugs in the past 5 years?
Situation Information
Please answer the following questions to help us better understand your situation:
Describe the issues you are struggling with.
What have you tried to do about your situation?
How do you hope counseling will help your situation? What are your expectations for coming here to receive counseling?
Do you have any additional information that might help us to help you?
Scheduling, Payment, and Other Important Information
Days I can meet online (Zoom)
Times I can meet:
PLEASE CHECK ✅ I UNDERSTAND
There is a monthly charge which covers access to my counseling resources and my counseling sessions which are 2 to 4 times per month for 45 to 60 minutes with my counselor.
I am responsible for canceling my membership to Counseling Services when I complete my counseling sessions.This will ensure that my account has been closed and that my credit card will not be charged after I have completed my counseling.
VCLi Counseling Services are directive and Biblically based.
I am responsible for completing my weekly assignments.
We at Victorious Christian Living would like to thank you for coming to us for biblical counseling and trusting us with your personal struggles. We are grateful that you have chosen us as your source of help, and we will do our best to provide you with a safe space where you can find healing through God's Word. Your commitment to finding peace and joy in life is commendable, and we look forward to walking alongside as part of this journey.
Thank you again for trusting us!
