In-Take Forms

Sexual  Abuse  Intake  Information

Please  print  clearly.

Name:  _________________________________________________Date  submitted:  ________________

Address:  _____________________________________________________________________________

City:  _______________________________________________  State:  ________  Zip:  ________________

Daytime  Phone  #:  ____________________________  Main  Phone  #:  _____________________________

Email  Address:  ________________________________________________________________________

Date  of  Birth:  ____________________        Married            Divorced            Separated            Single            Widowed

Do  you  have  any  children  living  at  home?      Yes   No                    Do  you  have  children?            Yes              No

Is  your  abuse  confidential?  ______________  If  not,  who  is  your  support  person?  ___________________


Are  you  currently  or  have  you  ever:

been  under  the  supervision  of  a  Mental  Health  Professional?  ____________

taken  antidepressants  or  any  other  Mental  Health  Medication?  __________

Have  you  ever  attempted  suicide?              Yes            No                    If  yes,  what  year  did  this  occur?  ___________

Circle  the  following  that  apply  to  your  situation.            Fondling                  Molestation                        Rape

What  age  were  you  at  the  time  of  the  sexual  abuse?  ________  Was  penetration  involved?  ___________

Who  was  your  abuser(s)?    No  names  please.__  ______________________________________________

How  long  did  the  abuse  occur?  ___________________________________________________________


I  understand  that  I  am  joining  a  Bible  Study  group  that  is  intended  to  help  me  understand  who  I  am  as  a

Christian.    I  also  understand  that  a  therapy  group  is  not  being  provided  and  the  Bible  Study  leaders  are

not  professionals  but  are  experienced  through  life  experiences  only.    At  any  time  that  is  desired  by  me

or  the  Bible  Study  leader,  I  will  be  willing  to  accept  referrals  to  a  professional.    I  understand  that  Lone

Star  Cowboy  Church  is  not  attempting  to  present  any  employee  or  volunteer  as  professionals,  but  has

approved  the  use  of  Bible  Studies  to  help  in  the  process  of  spiritual  and  emotional  growth.

Date:  _______________  Signature:  _______________________________________________________

Bible  Study  Leader  Signature:  _____________________________________________________________







Please  print  clearly.


Name:  _____________________________________________________________________________

1.)    What  statements  are  true  of  you.

_____  I  believe  that  I  was  molested  at  some  time  in  my  life,  but  the  past  is  something  that  I  avoid.

_____I’m  sure  I’ve  been  sexually  abused,  but  I  don’t  know  who  did  it.

_____  I’m  sure  that  I  have  been  sexually  abused,  but  I  don’t  have  clear  memories.

_____  I  have  clear  memories  of  being  sexually  abused,  but  I  am  not  sure  that  I  am  ready  to  face  them.     _____  I’m  having  problems  being  able  to  function  in  normal  situations,  ie.  family  events,  large  groups  of

people  known  or  unknown.

_____  I  have  fear  of  being  alone  with  certain  types  of  people  but  still  do  not  believe  that  my  sexual   abuse  has  damaged  me.     _____  I  don’t  believe  that  sexual  abuse  has  affected  me.     _____  I  am  not  sure  that  my  past  sexual  abuse  has  affected  me.     2.)  I’m  feeling:   _____  skeptical         _____  sad

_____  hopeful         _____  fearful

_____  hopeless         _____  confused

_____  angry         _____  desperate

_____  proud  of  myself  for  even  considering  taking  this  Bible  study

_____  I  have  been  working  on  my  past  issues  for  a  long  time  and  am  not  sure  what  to  do  next.

_____  I  don’t  know  what  I  am  feeling.

_____  I’m  not  sure  that  I  want  to  deal  with  my  past  sexual  abuse.

_____  I  am  not  sure  that  I  can  tell  anyone  about  my  past,  it  scares  me  to  be  real  with  people.

_____  I  have  taken  Bible  studies  or  counseling  before  and  have  been  disappointed  in  the  results.

_____I  have  taken  Bible  studies  or  counseling  before  and  am  excited  about  beginning  this  one.

_____  other  ______________________________________________






Pg.  2

3.)    What  do  you  want  to  accomplish  by  taking  this  Bible  study?





4.)    If  new  memories  or  painful  memories  begin  to  bother  me,  I  will  handle  it  by….





5.)    By  taking  this  Bible  Study  I  want  to  see  change  in  my  life  in  the  area’s  of:

Myself  –





Others  –





God  –





6.)  If  you  anticipate  struggles  in  certain  areas,  can  you  describe  them  and  how  you  will  deal  with  them?


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