What is Biblical Counseling?
Getting Started
- Our Leadership Team
- Counseling Request Form

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Counseling Request Form

You will not be able to save your progress so plan to spend roughly 30 mins preparing this form, etc.

Due to the high volume of counseling requests, there may be an extended wait time of a couple of months.

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1. Our Counseling: In association with Grace Bible Church (GBC), the Community of Grace Biblical Counseling Center offers Biblical Counseling. Biblical Counseling refers to a philosophy of counseling that is faith-based, believing that the Bible is God’s word to mankind to be applied to the struggles of life that we all suffer. We believe that the Bible is without error, is authoritative, and is sufficient to provide God’s answers to the spiritual issues of life, conduct, and relationships. We do not base our counseling on psychology. If you have questions relating to legal, financial, medical, or technical matters, it is best to seek advice from others in those specific fields. Our counselors will be happy to cooperate with those advisors and help you to gain biblical perspectives and seek biblical solutions. As an expression of our love for the Lord Jesus Christ and our desire to serve the community that we live in, our counseling is free of charge.
2. Our Counselors: All of our counselors have completed a training process to equip them to competently use the Bible as their source of authority. While a number of our counselors are certified through the Association of Certified Biblical Counselors (ACBC) or a similar certification organization, none are licensed by the state of Montana. GBC is active in training others to be Biblical Counselors. Part of their training is to observe counseling sessions. Therefore, there may be another person sitting in during your counseling sessions. They are bound by the same confidentiality guidelines as outlined below.
3. Confidentiality: We wish to respect your privacy and maintain confidentiality about counseling issues. There are certain exceptions:
4. Resolution of Disagreement: Any disputes will be settled through a form of Christian conciliation, such as the conciliation division of Ken Sande's Relational Wisdom 360 (rw360.com).
I agree to the above agreement*
- Yes
- No
Signature*
First Last
Please fill your name here as your signature.
Preferred means of communication:
- Phone Call
- Text Message
Expect to receive a call/text from the Counseling Center receptionist (406-946-9782) on the next business Monday.
Preferred Monday counseling time:
- 3:30pm
- 6:00pm
- 7:30pm

Date*
MM slash DD slash YYYY
Personal Identification
Name*
First Last
Best phone number to contact you*
Address
Street Address City State ZIP Code
Email
Sex*
- Male
- Female
Age*
Birthdate*
MM slash DD slash YYYY
Education (last year completed)
Business/Work Phone
Employer
Position
Years in position
Health Information
Rate Your Health*
- Very Good
- Good
- Average
- Declining
Do you have any chronic conditions?
- Yes
- No
If yes, please describe
List important illnesses and injuries or handicaps
Date of last physical exam
MM slash DD slash YYYY
Weight Changes Recently
- Lost
- Gained
- n/a
Amount of weight lost
Amount of weight gained
Your Physician's Name
Please list current medications
Have you ever used drugs for other than medical purposes?*
- Yes
- No
What?
If yes, please explain
Have you ever had a severe emotional upset?
- Yes
- No
If so, explain.
Have you ever been convicted of a crime?*
- Yes
- No
If so, explain.
Do you have problems sleeping?
- Yes
- No
- Sometimes

Religious Background
Denominational Preference
Church currently attending*
How many sundays do you attend per month?*
Are you an official member of that church?*
- Yes
- No
Are you actively involved in an official ministry in your church?*
- Yes
- No
Church attended as a child
Have you been baptized?*
- No
- Yes, as an adult
- Yes, as an infant
Religious background of spouse (if married)
Do you consider yourself to be a religious person?*
- Yes
- No
- Uncertain
Do you believe in God?*
- Yes
- No
- Uncertain
Do you pray to God?*
- Never
- Occasionally
- Often
How often do you read the Bible?*
- Never
- Occasionally
- Often
Are you saved?*
- Yes
- No
- Not sure what you mean
If you were to die tonight, do you know with absolute certainty that you would go to heaven?*
- Yes
- No
- Uncertain
If you were to die today and stand before God and He were to ask you, “Why should I let you into my heaven”, what would you say?*
Do you have regular devotions?
- Yes
- No
- Not sure what you mean
Explain recent changes in your religious life, if any:

Marriage and Family
Marital Status*
- Single
- Dating
- Engaged
- Married
- Separated
- Divorced
- Widowed
Name of Spouse
Age of Spouse
Education of Spouse (in years)
Spouse's Occupation
Number of years Spouse Employed
Phone number of spouse
Date of Marriage
MM slash DD slash YYYY
Length of Dating
Give a brief summary of circumstances of meeting and dating
Husband's Age When Married
Wife's Age When Married
Have you ever been separated?
- Yes
- No
Have you ever filed for divorce?
- Yes
- No
Have either of you been previously married?
- Yes
- No
If yes, who?
Give a brief information about any previous marriages:

Personality Information
Have you ever had any psychotherapy or counseling before?*
- Yes
- No
If yes, list counselor or therapist and dates
What was the outcome?
What, if anything, do you fear?
Is there any other information that would help us to help you?
Have you recently suffered a loss from serious social, business, or other reversals, etc?
- Yes
- No
Explain if yes
Check any of the following words which best describe you now:*
- Active
- Ambitious
- Self-Confident
- Persistent
- Nervous
- Hardworking
- Impatient
- Impulsive
- Moody
- Often-blue
- Excitable
- Imaginative
- Calm
- Serious
- Easy-going
- Shy
- Good-natured
- Introvert
- Extrovert
- Likable
- Leader
- Quiet
- Submissive
- Self-conscious
- Lonely
- Sensitive
- Other
You selected other, please explain
Do you drink coffee or other caffeinated drinks?*
- Yes
- No
How much caffeine per day?
Do you smoke?*
- Yes
- No
How much do you smoke?
Do you explode when you get angry?*
- Yes
- No
Do you withdraw when you get angry or hurt?*
- Yes
- No
Do you frequently argue with significant other people?*
- Yes
- No
Have you ever been enslaved to anything (Coffee, drugs, alcohol, pornography, gambling, etc.)?*
- Yes
- No
If yes, please explain.*

Fear of Man Questionnaire
Fear of Man Questionnaire*
- I struggle with peer pressure. In adulthood, it looks different than when a teen. Now it might be by trying to impress others.
- I am over-committed. I find it hard to say, “No.” I am a people pleaser.
- I ‘need’ something from my spouse or others in my life (such as the person I am dating, a roommate, other friends).
- I feel like I have low self-esteem. I am concerned with what others think of me.
- I often feel like I will be exposed as an imposter. I am afraid others will think I am a failure.
- I find myself second-guessing decisions because of what others might think. I am afraid of making mistakes.
- I feel empty or meaningless. I often feel hungry for love.
- I easily get embarrassed.
- I lie, even little white lies, in order to make myself look better before other people.
- I am sometimes jealous of other people.
- People often make me angry or depressed. They make me “crazy.”
- I often avoid people.
- I am hungry for people to notice my efforts and to praise me, but when they do, it’s not enough or I don’t believe them.
- I often compare myself to others and either feel wanting or feel like I’m not so bad.
- I feel I have to keep others from knowing my secret thoughts or actions for fear they won’t like or love me.
- I cover up, justify, blame, avoid, or change the subject often.
- I show favoritism, respecting one person over another.
- I often think and feel responsible for other people and their actions or behaviors.
- I am compelled to “fix people”.
- I get tired of feeling like I am always giving to others and no one gives to me.
- I blame others or blame circumstances.
- I often feel unappreciated.
- I often am afraid of being rejected.
- I often feel ashamed of who I am.
- I often focus my energy on other people and/or on problems.
- I frequently threaten, bribe, or beg.
- I try to say or do what I think will please others or get what I want.
- I manipulate people and situations.
- I let other people keep hurting me and never say anything.
- I feel angry.
- I feel like a martyr.
- I feel extremely responsible or irresponsible.

Briefly answer the following questions
What is the main problem as you see it? What brings you here?*
What have you done about your problem?*
What can we do? (What are your expectations in coming here?)*
As you see yourself, what kind of person are you? Describe yourself:*
Give details of any family background that might be pertinent to the struggles in your own life. (I.e., do others in your family have similar problems? What did your home life look like? Did mom lead or dad? Was dad at home a lot or gone a lot? Was “self-control” taught from early on? Etc.
Problem Checklist (Check those which are current problems)*
- Anger
- Fear
- Moodiness
- Health
- Sleep
- Deception
- Adultery
- Envy
- Memory
- Bitterness
- Sex
- Depression
- In-Laws
- Lust
- Appetite
- Apathy
- Guilt
- Children
- Impotence
- Self-harm
- Addiction
- Anxiety
- Gluttony
- Rebellion
- Sexual identity
- Spouse Abuse
- Change in Lifestyle
- Other
You answered other, please explain.
Is there any other information we should know?*

Home
What is Biblical Counseling?
Getting Started
Our Leadership Team

Grace Bible Church

3625 South 19th Ave
Bozeman, MT 59718
T. (406) 586-9782

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