BIBLICAL COUNSELING Grace Church Counseling Ministry Please complete this inventory carefully. "*" indicates required fields Step 1 of 8 12% Counseling Agreement Policy Grace Church Counseling Ministry It is our joy at Grace Church to provide ministry to those in need of counseling. We believe that Christian counseling can be a timely and important aid to your spiritual growth so it is our aim to conduct our meetings and to steward your personal information in a way that honors God and provides the most hope and help to you. It is vital to our usefulness to you that you make the following acknowledgments and agreements and give the following consents: The counseling will be by a counselor who has received some training in Biblical counseling, but that may not have other certifications or degrees. Their credentials are not issued by the state of Montana and they hold no state issued license to practice. The counsel you will receive from us is based upon scriptural principles rather than principles of psychology or psychiatry. The counsel you will receive will be based on the conclusions that the Bible is inerrant and authoritative, and contains God’s answers to the issues of life, conduct, and relationships. The counsel you will receive will reflect the counselor’s understanding of the Bible and how the principles of scripture apply to the problems, questions, or issues involved. Your responsibility is to make sincere effort to embrace and apply the teaching of God’s word as it is applied to your life-situation. If you do not have a home church, you must make the commitment to regularly attend Grace Church while receiving counseling from this ministry. Counseling at Grace Church, including the statements made during counseling sessions, shall remain confidential, with the following qualifications and exceptions: When a leader is uncertain of how to counsel a person about a particular problem and needs to seek advice from other leaders in our church or, if the person attends another church, from the leaders of that church (Prov. 11:14); When the person who disclosed the information, or any other person, is in imminent danger of serious harm unless others intervene (Prov. 24:11-12); When a person refuses to repent of sin and it becomes necessary to promote repentance through accountability and redemptive church discipline (Matt. 18:15-20); or When leaders are required by law to report suspected abuse (Rom. 13:1). Counselors reserve the right to discuss any and all counseling situations with the leadership at Grace Church. If you are unwilling to use the Bible as the final authority in counseling or are unwilling to do the homework assigned, sessions will be terminated by the counselor. In any counseling case where abuse is alleged or suspected, an elder, pastor, or additional counselor, subject to the situation or counselor's discretion, will immediately begin attending subsequent counseling sessions and will assist in investigating the claimed abuse situation. There may be times when a person being trained to do biblical counseling sits in on counseling sessions for the purpose of observation. These individuals have agreed to all elements of confidentiality noted above. For long term counseling, it is always our goal to match women counselees with women counselors, and men with men. If that is not possible, we will ensure that there are at least two people present in the instance of a man counseling a woman. Consent* I have read, I understand, and I agree to these guidelines Personal IdentificationName* Today's Date* MM slash DD slash YYYY Age* Email* Address* Phone* Health InformationRate your Health Very Good Good Average Declining Other Other: Do you have any chronic conditions? Yes No Explain Have you had any recent changes in weight? Yes, gained Yes, lost No change List important illnesses or handicaps Date of Last Exam MM slash DD slash YYYY Report from last medical examination Your Physicians name and address Are you presently taking medications? Yes No What medication? Previous medication(s) taken and dosage (if you remember) Have you ever used drugs for other than medical purposes? Yes No Please Explain Have you ever had a severe emotional breakdown? Yes No Please Explain Have you ever been arrested? Yes No Please Describe Do you have problems sleeping? Yes No Sometimes Please Describe Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? Yes No Family InformationMarital Status Single Dating Engaged Married Separated Divorced Widowed Spouse's Name Spouse's Age Date of Marriage MM slash DD slash YYYY Length of Dating Have either of you been previously married? Yes No Who Information about ChildrenPlease list the name, age, and sex of each child 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.) Religious InformationWhat church do you attend? Religious Background Religious Background of Spouse (if married) How often do you read the Bible? How often do you pray to God? 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? How often do you attend Sunday morning church service? Are you a part of any other studies/church groups? How often do you serve others? Give one example How often do you disciple/are you discipled by other Christians? Please explain what this looks like Explain recent changes in your religious life, if any Personality InformationHave you ever had any psychotherapy or counseling before? Yes No List counselor or therapist and dates What was the outcome? What, if anything, do you fear? Have you recently suffered a loss from serious relational, social, business, or personal life changes? Yes No Explain Select any of the following words which best describe you now: Active Ambitious Self-Confident Persistent Nervous Hardworking Impatient Impulsive Moody Often-blue Exciteable Imaginative Calm Serious Easy-going Shy Goodnatured Introvert Extrovert Likeable Leader Quiet Submissive Self-concious Lonely Sensitive Other Other Personality Behavior HabitsDo you drink coffee or other caffeinated drinks? Yes No How much per day? Do you Smoke? Yes No How often? Do you explode when you get angry? Yes No Do you withdraw when you get angry or hurt? Yes No How frequently do you get into arguments? Have you ever been enslaved to any of the following: Coffee Drugs Alcohol Pornography Gambling Other None Please Explain Briefly Answer the Following QuestionsWhat 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:Is there any other information we should know?Problem Checklist (Check those which are current problems) Anger Fear Bitterness Sex Children Memory Deception Envy Depression Guilt Adultry Impotence Rebellion Change in Lifestyle Appetite Apathy Health Lust Addiction A Vice Anxiety Gluttony Moodiness Wife Abuse Husband Abuse Sleep In-Laws Other Other: PhoneThis field is for validation purposes and should be left unchanged.
