Women’s Covenant Counseling — Intake Form | Covenant Restoration
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Women’s Covenant Counseling  ·  Pastoral Intake Form
Welcome, Sister
Before We Begin

This form is your first step toward the most honest conversation you may ever have about who you are, where you have been, and where God is taking you. Nothing you write here will be used against you. Everything you share stays between you and Pastor Chiquita. There are no wrong answers — only honest ones. Take your time. Find a private place. You are safe here.

Section 1 of 8

Who Are You

Basic information and your current life situation
Full Name
Date of Birth
Phone Number
Email Address
01
What is your current relationship status?
02
How old are you, and how long have you been connected to this ministry?
03
Describe your current living situation — who do you live with, what does your daily life actually look like?
04
Do you have children? If so, how many, what are their ages, and describe the co-parenting situation if applicable.
05
What do you do for work, and are you proud of what you do?
06
How would the three people closest to you describe you — honestly, not how you would want them to?
07
How would you describe yourself — your actual identity, not your roles? Who are you when nobody is watching and nothing is required of you?
08
What brought you to counseling right now — what happened or what season prompted this decision?
09
Have you received counseling — pastoral or professional — before? If so, what happened and why did it end?
10
What do you hope to walk away from this counseling process with — not what you think you should say, what you actually want?
11
What is the one area of your life you least want to talk about in this process?
This answer often reveals exactly where the work needs to happen.
Section 2 of 8

Wounds & History

Your story — what shaped you, what hurt you, what you carried
12
Describe the home you grew up in — who raised you, what was the atmosphere, and what did love look like in that household?
13
What was your relationship with your mother like? Describe it honestly — not what it should have been, what it actually was.
14
What was your relationship with your father like — present, absent, or somewhere in between? How did that shape your relationship with men?
15
What is the wound you have carried the longest — the one that has followed you from relationship to relationship, season to season?
16
Was there a specific moment in your childhood or adolescence that changed how you saw yourself, men, or the world? What happened?
17
How do you typically handle anger — do you express it, suppress it, redirect it inward on yourself, or redirect it outward onto others?
18
Is there someone you have not forgiven — a parent, a man, a friend, yourself? Describe the situation without naming the person if you prefer.
19
What grief are you still carrying that you have never fully processed — a loss, a death, a relationship that ended, a version of yourself you mourned?
20
Have you ever struggled with depression, anxiety, self-harm, eating disorders, or thoughts of suicide? You do not have to share details — a yes or no with whatever context you are comfortable giving is enough.
21
What has been the hardest season of your life so far, and what did it reveal about you — for better or worse?
Section 3 of 8

Faith & Theology

Your real relationship with God — not the Sunday answer, the honest one
22
Describe your relationship with God right now — not what it should be, what it actually is today.
23
Is Jesus your Lord or your Savior in the way you actually live — not how you describe yourself? What areas of your life are still running on your own terms?
24
How is your prayer life honestly? How often do you pray, what do you pray about, and do you ever just listen?
25
Do you tithe? Write your honest relationship with tithing — not the theological answer, the practical one.
26
Have you ever been spiritually manipulated or abused — by a pastor, leader, or man who used God’s name to control, guilt, or take advantage of you?
This is more common than most women admit in church. Your answer here stays completely confidential.
27
What do you believe God thinks of you right now — not what you know He should think, what you actually feel He thinks of you?
28
Is there an area of your life where you are angry at God — where something happened that you have never fully resolved with Him?
29
Do you believe you need deliverance from anything — a pattern, a bondage, a stronghold that prayer and willpower alone have not broken?
30
What would it mean for your faith to actually cost you something? Is there anything God is asking of you that you have been avoiding?
Section 4 of 8

The Code She Carried

The survival system you built — honest, no judgment

Every woman builds a code to survive — a set of tools she learned to use when she felt powerless, unseen, or unsafe. This section is not about judging how you survived. It is about understanding what you built so we can examine what still needs to be replaced by covenant truth.

31
Have you ever used your appearance or beauty as a tool to get what you needed — attention, protection, provision, access, or power?
32
Have you ever used sex as a weapon — offering it to get something you needed or withholding it as punishment?
33
Have you ever manipulated a man — through tears, silence, guilt, emotional pressure, or indirect tactics — to get a specific outcome?
Be honest. This is one of the most common patterns women develop and one of the least talked about in church. 1 Samuel 15:23 — manipulation is as the sin of witchcraft.
34
Have you ever lied or withheld truth in a relationship — not to protect yourself from danger, but to control an outcome or avoid accountability?
35
Have you ever performed — been whoever the room needed you to be — while hiding who you really were underneath?
36
Have you ever people-pleased to the point of losing yourself — agreeing, accommodating, and shrinking so others would not leave, be angry, or disapprove of you?
37
Have you ever used emotional withdrawal — shutting down, going cold, or disappearing emotionally — as a way to punish or control someone?
38
Have you ever used caretaking or being needed as a way to keep someone close — doing for others what they should do for themselves so they would not leave?
39
Looking at the patterns above — where did you learn these tools? What situation or person first taught you that this was how to survive?
40
Which of these patterns is still most active in your life right now — the one you still reach for under pressure?
Section 5 of 8

Sexuality & Soul

Your sexual history and what it has cost you — handled with complete confidentiality

This section requires complete honesty and will be held in absolute confidence by Pastor Chiquita. You are not being judged for your past. You are being given the space to name it so healing can actually begin. Answer as much or as little as you are ready to share — Pastor Chiquita will go deeper with you in session.

41
Have you ever been sexually violated, abused, or assaulted — as a child or as an adult?
You do not need to share details here. A yes or no, or as much as you are comfortable sharing, is enough. This information helps Pastor Chiquita create a safe and appropriate counseling environment for you.
42
Have you ever had an abortion?
This is asked with deep compassion. You are not being judged. Many women carry this silently for years or decades. This counseling process creates space for real healing around it — not condemnation.
43
What does sex mean to you — not what it should mean, what it has actually meant in your life? What need has it met, what role has it played?
44
Are you currently sexually active outside of marriage?
45
Have you ever felt pressured, manipulated, or coerced into a sexual situation — even if it did not fit the definition of assault?
46
Do you believe you carry soul ties from past relationships — emotional or spiritual connections that did not break when the relationship ended?
47
Do you struggle with pornography, sexual content, or sexual fantasy as a recurring pattern?
48
What has your sexual history cost you specifically — in your self-respect, your spiritual life, your ability to trust, or your relationship with your own body?
49
Is there a sexual wound, regret, or secret you have never spoken aloud to anyone? You do not have to name it here — but acknowledge that it exists if it does.
50
What would sexual wholeness look like for you — not just behavior, but freedom in your mind, your body, and your spirit?
Section 6 of 8

Safety & Relationships

Your relational history and your current safety — confidential

Important: If you are currently in a situation where you feel unsafe, please know that your safety matters more than any counseling process. If you need help right now, contact the National Domestic Violence Hotline: 1-800-799-7233 (available 24/7). Pastor Chiquita will address safety concerns in your first session.

51
Have you ever been physically abused — hit, slapped, choked, pushed, kicked, or otherwise physically harmed by a partner, family member, or anyone else?
52
Have you ever been emotionally abused — controlled, isolated, belittled, threatened, or manipulated by someone who claimed to love you?
Emotional abuse does not always leave visible marks, but it leaves real wounds. Name it if it happened.
53
Have you ever been used — financially, emotionally, sexually, or otherwise — by someone you trusted? Describe what that looked like.
54
Describe your pattern in romantic relationships. What tends to happen? What role do you typically play — the fixer, the giver, the one who holds on too long, the one who runs?
55
Do you find yourself repeatedly attracted to the same type of man even when that type has not been good for you? Describe what that type looks like and what draws you to him.
56
Have you ever stayed in a relationship longer than you should have? What kept you there?
57
How do you handle it when someone you love disappoints you — do you confront, withdraw, forgive quickly, hold a grudge, or pretend it did not happen?
58
Do you trust women? Describe your friendships with other women honestly.
59
Are you currently safe — in your home, in your relationship, in your daily life?
60
Is there a relationship in your life right now — romantic, family, or friendship — that you know is unhealthy but you have not been able to leave or change?
Section 7 of 8

Motherhood & Family

Your children, your household, and your vision for family
61
Are you a biological mother, a stepmother, acting in a mothering role, or not yet a mother? Describe your current situation honestly.
62
If you have children — describe your relationship with each of them individually. Where is it strong, and where is it strained?
63
What does your relationship with your own mother tell you about the kind of mother you are or want to be — what are you repeating and what are you determined to change?
64
What is your philosophy of discipline and correction with children — not what sounds right, what you actually believe and practice?
65
If you are in a co-parenting situation — how is that relationship? Is there unresolved conflict, bitterness, or competition between you and the child’s other parent?
66
How are you spiritually raising your children — or how do you plan to? Is there a gap between what you intend and what you are actually doing?
67
What does the word “family” mean to you — not the definition, what feeling or image comes when you hear it?
68
What kind of household do you want to build — and what is currently in the way of that vision?
69
If your children — current or future — grew up to be exactly like you are right now, would that be a good thing? Why or why not?
Section 8 of 8

Money, Covenant & Self-Awareness

Your financial habits, your readiness for covenant, and what you know about yourself
70
What does money mean to you emotionally — security, freedom, power, proof of worth, survival? Where did that meaning come from?
71
How was money handled in the home you grew up in? Was there enough? Were there arguments about it? Was it talked about openly or treated as secret?
72
Describe your current financial situation honestly — income, debt, savings, and habits. Do you budget? Do you save?
73
Have you ever used money — or financial dependency — as a way to stay in or control a relationship? Or has someone used money to control you?
74
Have you ever experienced significant financial failure — debt, bankruptcy, a decision that cost you greatly? What did it teach you?
75
What does covenant marriage mean to you — not culturally, biblically? What would it require of you personally and specifically?
76
What do you believe a husband should be and do? Where did those beliefs come from — Scripture, your father, culture, or past relationships?
77
What do you believe about biblical submission — not what you have been told, what you actually believe and how it sits with you honestly?
78
What is the biggest obstacle standing between you and a healthy, covenant relationship right now?
79
What do you know about yourself — a pattern, a truth, a fear — that you have never told anyone and that you believe God is asking you to finally bring into the light?
80
What is the version of yourself you most want to become through this counseling process? Describe her.
81
Are you ready to be completely honest in this counseling process — even when it is uncomfortable, even when it reveals things about yourself you would rather keep hidden?
82
Is there anything else Pastor Chiquita should know before your first session that this form did not ask?
83
Look honestly at the five patterns below. Each one has shown up in this form in different ways across different sections. Circle or select the one that has had the most power and control over your life — the one that, if you are honest, has driven the most damage, the most wrong decisions, and the most distance from God and from healthy love.
There is no wrong answer. This is not about shame — it is about naming the root so Pastor Chiquita knows exactly where to begin.
THE FIVE PATTERNS — 1 CORINTHIANS 10:6-11
Explain why you chose this one — be specific:

◆ Before You Submit ◆

By submitting this form you confirm that your answers are honest to the best of your ability, and that you understand everything you share is held in complete pastoral confidence by Pastor Chiquita Jackson. You are not being judged. You are being seen. You are safe here.

Your responses go directly and confidentially to Pastor Chiquita Jackson. She will review them before your first session.

✓ Received

Thank you for your honesty and courage. Pastor Chiquita will review your form and reach out to schedule your first session. You took a brave step today.

Covenant Restoration  ·  McDonough, Georgia
Women’s Covenant Counseling  ·  Pastoral Intake Form  ·  Confidential
We War · We Love · We Disciple · We About Our Father’s Business