Male Pre-Counseling Intake Form | Covenant Restoration

Covenant Restoration Pastoral Counseling

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Prefer pen & paper? Print this form and return it before your session.

Male Pre-Counseling Intake Form

From the Foundation Up — A Journey Toward Covenant Manhood

A word before you begin:
This form is not a test. There are no right answers — only honest ones. Every question here exists because the depth of what God wants to do in you and through you requires us to start with truth. You cannot build a covenant life on a concealed foundation.

Take your time. Find a quiet place. Answer alone. This is between you and God first — and then between you and me. Honesty is not optional here. It is the covenant we make before the first session begins.

— Pastor Anthony Jackson II

◆ Covenant of Honesty ◆

By completing and submitting this form, you agree to answer every question with full honesty — even when it is uncomfortable. You understand that this counseling process is built on truth, and that concealment will only delay the breakthrough God has for you.

Before We Begin

Your Information

Basic details so Pastor Anthony can prepare for your session.

Full Name *

Age *

Phone Number

Email Address

Name of the woman you are planning to marry (if applicable)

Section 1 of 8

Who Are You

Identity & Background — We establish the man before we touch anything else.

01Where are you from? Describe your upbringing and cultural background.

02Describe your relationship with your father. Is he present in your life?

03How do you view your mother? What role has she played in shaping who you are?

04How do you see yourself right now?

05Where do you see yourself in 5 years? In 10 years?

06What are your strengths?

07What are your weaknesses?

08What do you consider fun? What is relaxation to you? Do you rest?

09How often do you read? How actively are you leveling up your skills in what you love to do?

10Are you working in a field you are proud of?

Yes No Not yet

Section 2 of 8

Your Wounds & Your History

Pain, Patterns & Past — We go beneath the surface. Answer honestly, even when it hurts.

11Have you ever been hurt deeply — emotionally, physically, or spiritually? Describe it.

12When was your first heartbreak? How old were you and how did you handle it?

13Have you ever struck a woman, even as a child?

Yes No

14Have you ever hurt a woman emotionally or psychologically?

Yes No

15Have you ever used a woman for sex?

Yes No

16Have you ever cheated on a woman?

Yes No

17Have you ever manipulated a situation to gain something — no matter what it was?

Yes No

18Have you ever had sex with another man’s wife?

Yes No

19Have you ever stolen before?

Yes No

20Have you ever consigned or gone along with rude or wicked behavior?

Yes No

21Who are the people you refuse to forgive? What grudges are you holding?

22Do you truly want forgiveness — from God and from others?

Yes No I’m not sure

23Have you thought about cheating on the woman you are with now?

Yes No

24Do you feel there is a woman too close to you that would cause you to stumble?

Yes No

25How do you handle conflict in general?

26How do you handle conflict in your relationship?

27Are you a jealous man? How do you feel when your woman is around men you don’t know?

28Do you complain often?

Yes No Sometimes

29Do you lust after things — people, possessions, status?

Yes No Sometimes

Section 3 of 8

Your Faith & Your Theology

Spiritual Foundation — This section separates religion from relationship.

30What are your views on God?

31Is Christ your Lord or your Savior?

There is no coached answer here — only an honest one. Answer exactly as you feel.

Lord Savior Both I’m not sure

32What is your faith like on a daily basis?

33Do you believe in prayer?

Yes No Somewhat

34Do you believe in fasting?

Yes No I’ve never tried

35Do you believe in tithing?

Yes No Not sure

36What does discipleship mean to you? Do you believe in it?

37What do you think when you hear the word deliverance?

38Do you believe you have ever tempted God?

Yes No I’m not sure what that means

39Do you have idols or have you ever practiced idolatry?

Yes No I’m not sure

40Do you know the difference between the flesh and the spirit?

41Do you hear or do you listen — and do you know the difference?

42Are you good at asking questions?

Yes No I’m working on it

43What does wealth mean to you? What does abundance mean to you?

44Do you hate prosperity gospel? Do you believe that just enough is sufficient, or are you looking to be prosperous?

Section 4 of 8

Your Sexuality & Soul

Sexual History, Soul Ties & Purity — Answer what most men have never confessed out loud.

45What does sex mean to you?

46Are you actively in fornication?

Yes No

47Do you masturbate?

Yes No Occasionally

48What do you know about soul ties?

49How many women from your past relationships do you still deal with outside of the mother of your children?

50Why didn’t you marry the other women you were with?

51Do you believe your past sexual history has affected who you are today?

Yes No I’m not sure

Section 5 of 8

Fatherhood & Family

His View of Family, Children & Legacy — What kind of man will your children know?

52What does being a father look like to you?

53Are you a biological father, a stepfather, or acting in a stepfather role?

Biological father Stepfather Acting stepfather role Not a father yet

54How do you see yourself as a father?

55Did you see a healthy marriage growing up?

Yes No Somewhat

56Do you expect your marriage to be like your parents’? Do you want it to be?

57What does it mean for a man to provide for his family?

58Do you consider the husband the sole provider?

Yes No It depends

59How do you plan on governing your household?

Section 6 of 8

Marriage & Covenant

Readiness, Expectations & Understanding of Covenant — The deepest questions begin here.

60Why do you want to marry this woman?

61Can you see God in her?

Yes No I’m not sure

62Have you and this woman already had sex?

Yes No

63Has she ever broken your heart? Has she ever upset you and you held it in?

64Did you ever tell her how you felt — or did you sit on it until it changed how you see her or interact with her?

65Do you believe she would hurt you? Do you believe she would cheat on you?

66Do you believe she should have male friends? Should you have female friends?

67What is the difference between a contract and a covenant?

68What does it mean to serve?

69Are you willing to die to self — and do you understand what that means?

Yes No I’m learning

70What roles do you expect in marriage?

71What do you expect from your wife?

72Have you ever been married before?

Yes No

73What would stop you from getting married — not just to this woman, but in general?

74Do you feel pressured to be married? If so, by whom?

Yes No

75How do you feel marriage would change you?

Section 7 of 8

Money & Stewardship

Financial Mindset & Responsibility — Money will test your marriage. Let’s see where you stand.

76What does money mean to you?

77Do you believe in investing money?

Yes No I want to learn

78How much time do you spend investing in yourself — your skills, your mind, your health?

79What does wealth mean to you? What does abundance mean to you?

80Are you looking to be prosperous — or do you feel that just enough for you and your family is sufficient?

Section 8 of 8

Self-Awareness & Readiness

The Mirror — The final questions. Look at yourself honestly before the journey begins.

81What do you consider a punk? Be honest.

82What makes a man weak?

83If I told you that 5 things hold men back, what 5 things do you believe they are?

List them honestly. There is no coached answer.

84What do you know about repentance?

85Do you believe this counseling is here to fix you?

Yes No I’m not sure

86What are you expecting to receive from Pastor Anthony?

87What are your expectations of these sessions?

88What are your expectations of yourself through this process?

89What are your expectations of marriage?

90Why do you feel you need counseling?

91Whose idea was it to seek counseling?

Mine My partner’s Someone else suggested it Mutual decision

92What does getting counseling really mean to you?

◆ Covenant of Commitment ◆

You have answered questions most men never face. That took courage. Now comes the most important question of all — not about your past, but about your willingness to move forward.

“Are you willing to be fully committed to this journey — no matter what surfaces?”

Yes, I am fully committed I want to be, but I have concerns I’m not sure yet

By typing your full name below, you acknowledge that every answer you have given is honest to the best of your ability, and that you enter this counseling process with a willingness to be transformed — not just informed.

Your responses will be sent securely to Pastor Anthony before your Session 0.

✓ Form Received

Thank you for your honesty and courage. Pastor Anthony will review your responses before your first session. You will be contacted to confirm your Session 0 appointment.

Covenant Restoration · McDonough, Georgia

Pastoral Counseling · Confidential

We War · We Love · We Disciple · We About Our Father’s Business