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Biblical Counseling MinistryPage 1 of 9 Biblical Counseling Ministry (Name of Church) (Church Address) Phone: Fax: Biblical Counseling Ministry Please take a moment to read this letter carefully. Please read carefully and then each person seeking counseling must initial, sign, complete and return one of these forms to the address below. Removal of any pages from the form will cause it to be incomplete and may cause delay in the counseling process. You will only be contacted concerning your initial appointment after our office has received your completed paperwork. We can then proceed with setting up an initial “intake session” which will aid in your placement, or we can make an appropriate referral if we cannot meet your needs due to our waiting list and/or training and abilities. Please note that generally speaking, our appointment times are Monday through Thursday 9:00 A.M. – 4:00 P.M.. We will attempt to accommodate times that will work for your schedule as much as our availability allows. Please mark the return envelope as CONFIDENTIAL and mail the completed form(s) to the following address: (Name of Church) Attn: Intake Personnel (Street Address) (City, County, State, Zip Code) Our physical address is different than the church address. Please notice the location address at the top so you will know how to get to our office. We look forward to ministering to you in the capacity that the Lord has called us. Placement and/or Referral: We strive to match your need with an appropriate member of our ministry team. Therefore, you will likely have an intake interview which allows our placement coordinator to make placement or referral decisions to best meet your needs. We are ethically required to refer issues that are outside the scope of our ministry, or issues that we cannot address in a timely manner, to other professional providers. Your assigned counselor can Biblical Counseling MinistryPage 2 of 9 review their training and experience with you on your first session. Exceptions or changes in counseling placement require the ministry Director’s approval. Furthermore, we do not render any financial, legal or medical opinions and/or advice. Qualifications of Lay Counselors: Because of the Biblical and spiritual nature of this ministry, we train our own volunteers for the ministry of lay counseling. Lay-counselors do not possess professional licenses or certifications issued by the State of for the (Name of State) practice of professional counseling, marriage and family therapy, or social work specialties; nor do they necessarily possess the required education, experience or training for such licenses. Limitations of Confidentiality: Information disclosed to the counselors is considered confidential in nature and ethically cannot be disclosed, without written consent. In marriage or family counseling, all members involved in the counseling must sign a release. The following are exceptions that will result in confidentiality being waived:  Suspicion of child/elder abuse - We reserve the right and/or may be mandated by law to report child abuse or suspicion of child/elder abuse of any type to the proper authorities.  Threats to harm self or others - We reserve the right and/or may be mandated by law to disclose to the appropriate person, agency or civil authorities any threats of harm that a person may attempt or desire to do to one ’s self or to others.  Necessity of supervision - To insure the highest quality counseling outcome, our ministry functions as a “ministry team.” As a result, your lay counselor or intern will be supervised by one or all of the staff counselors. In addition, staff counselors also utilize peer supervision on an ongoing basis to provide the highest quality of service to our clients.  Necessity of consultation - We reserve the right to consult with other counseling professionals or appropriate church ministry staff members regarding your sessions. This consultation will be held in the same level of confidence as your sessions. No Court Testimony: The counseling we provide is faith-based and spiritual in nature. law prohibits compelled disclosure of these counseling exchanges, notes (Name of State) or records in any court of law. Accordingly, our counseling team will not provide court testimony and by signing below you are acknowledging this strict confidentiality and further agree that neither you nor your legal representative will attempt to subpoena your counselor for testimony. Waiver of Liability: In consideration for receiving any form of counseling from the Pastoral Counseling Ministry of , the person receiving the counseling (Name of Church) agrees to release and waive any and all claims of any kind against the ministry, staff, interns, lay counselor(s) or the Church, which may arise from, result out of, or be related to conduct or advice given. Resolution of Disagreements: If a dispute should arise between the person receiving ministry and the counselor (and/or the counseling staff or Church) regarding the counseling session or the Biblical Counseling MinistryPage 3 of 9 counselor’s advice or conduct, one should bring this dispute to the attention of the Director of the Pastoral Counseling Ministry. If the dispute cannot be resolved at this level, all parties agree to resolve such dispute by submitting to the Church’s Board of Elders for full and final resolution and conciliation. Counseling Files: All counseling files and their contents are the property of the Pastoral Counseling Ministry. Session summaries may be supplied, when appropriate, to other professional providers with your written release. Donations to Ministry: This ministry is made possible by the tithes and offerings of the members of . If you are not a consistent contributor to (Name of Church) we ask you to help support this ministry, based upon your (Name of Church) abilities, through donations while you are receiving counseling. Please make your checks payable to . (Name of Church) Days/hours for Counseling: Sessions are available only during office hours and only on an appointment basis. Possible Waiting List: Due to the volume of requests we receive, our ministry is primarily to the congregation. We will gladly see those in the (Name of Church) community, especially those with no church home, when our schedule allows. Members of will be given priority on our waiting list. If our waiting (Name of Church) list is prohibitive, we will offer outside referral options. Session Duration: Our ministry is designed to offer short-term counseling, typically ranging from 10-20 sessions. Issues requiring more extensive care may result in referral. A typical session is 50 minutes. Cancelling / Rescheduling: If you need to reschedule or cancel an appointment, we ask that you call at least 24 hours in advance . This allows us to reschedule others who are on our waiting list. Emergencies: This ministry does not provide 24/7 or after-hours crisis intervention. Unless otherwise directed by your counselor, if you are in crisis you should call 911, the Suicide Hotline @ 1-800-SUICIDE or go to the emergency room of your choice. What You Can Expect of Us: You can expect our ministry team to offer you acceptance, compassion and care as we provide Biblically based counseling that is within our scope of ministry. You can expect us to act on what we believe to ultimately be in your best interest aiming to promote in your personal, relational and spiritual growth. Biblical Counseling MinistryPage 4 of 9 What We Expect of You: Counseling is a cooperative venture with mutual responsibilities resting on both the counselor and the counselee. Therefore, we expect for you to approach the counseling process as an opportunity for personal change and spiritual growth; to focus on the changes God desires for your life, in the midst of your circumstances; to faithfully attend your sessions; to earnestly cooperate and participate in the counseling process as we all depend upon the guidance of God’s Word and the Holy Spirit; and to complete homework assignments that you and your counselor have agreed upon. Termination of Counseling: Termination of counseling and/or referral occurs when:  Counseling goals have been achieved;  When the counselee no longer wants or does not return to counseling;  When meaningful progress is no longer being made;  When it is determined that the counselee’s needs are outside the scope of our ministry;  When the counselee is not abiding by the policies of this ministry, or not consistently showing for appointments. In all such cases the counseling file goes on an inactive status and rescheduling will require the counselor’s approval. I, the undersigned, have carefully read, understand and agree to all of the above terms and conditions. I further acknowledge that all of the information contained on the following data sheets is true and complete to the best of my knowledge. Witness my signature this day of , 20 . (Signature) (Signature of Witness) (Printed Name) (Printed Name) Custodial parent or guardian must sign if counselee is under 18. (Name of Counselee) (Name of Counselee) By: By: (Signature of Parent or Guardian) (Signature of Parent or Guardian) (Printed or typed name) (Printed or typed name) Parent Parent Guardian Guardian Biblical Counseling MinistryPage 5 of 9 First Witness Signature Second Witness Signature Type or Print Name Type or Print Name This form will enable us to gain a quicker understanding of you and it will become a part of your confidential file. Please answer each question as completely as possible. If you are a couple, please fill out two forms, one for each person. Today’s date: Contact Information: Name: Phone: Cell Phone: Home Address: Work Address: Family member to notify in case of emergency: Emergency contact number: Relationship Sex: Male Female Birth date: Age: Highest level of education: Employer: Marital status: Single Engaged Married Separated (how long ) Divorced (how long ) Widowed (how long ) Name of Spouse Age of spouse Years married Biblical Counseling MinistryPage 6 of 9 Spouse’s Occupation and/or Employer This is your (e.g. first Marriage) This is your Spouse’s (e.g. second Marriage) Names and ages of children (indicate children from previous marriage with an *.) Name Age Who referred you to our ministry? Relationship Spiritual Life: What church do you currently attend? Are you a member? Describe your spiritual life currently: Health Care: (From whom or where do you get your medical care?) Doctor/clinic’s name: Phone: Doctor/clinic’s name: Phone: Please list any prescribed medications or over-the-counter medications (herbs, supplements, etc.), you are currently taking, the dosage, and the reason for taking. Unless otherwise noted, list any medications you have ever taken for any emotional or psychiatric problem? Which medication? When? From whom? For what reason? With what results? Biblical Counseling MinistryPage 7 of 9 Current or Prior Counseling/Psychological Care: Are you currently receiving or have you ever received any type of counseling, psychotherapy, psychiatric care or addiction recovery help? If yes, please indicate: From whom? When? For what reason? With what results? Have you ever been hospitalized for a mental, emotional or addiction issue? If so, list when, where and why? Date Place For what reason? Have you ever attempted suicide? YES NO Concerns Checklist: (check all that currently or recently apply to you) Anger / frustration Intrusive thoughts Employment problems Fearfulness Unsure of salvation Conflicts with co-workers Prolonged sadness Spiritual concerns/confusion Withdrawing from others Depression Distance from God Biblical Counseling MinistryPage 8 of 9 Social/relational stress Confusion Gambling problem Explosive anger Loneliness Pornography use Family tension Hopelessness Past abuse: physical/sexual Family / marital violence Anxiousness Past abuse: emotional/neglect Parenting struggles Guilt over the past Sexual concerns Marital difficulties Difficulty making decisions Physical problems Alcohol use/abuse Financial problems Substance use/abuse Other (specify) Presenting Problem(s) Please describe the reasons for seeking counseling: Please state what you have done so far to solve the problems you mentioned above: Biblical Counseling MinistryPage 9 of 9 On the scale below please estimate the severity of your problem(s): Mildly upsetting Moderately upsetting Very upsetting Extremely upsetting Please state your goals for counseling (how you hope to benefit from counseling): Please mark any recent loss / crisis: Family Relationships Health Financial/job Other (please explain) Is there anything else important for the placement coordinator or your counselor to know about, and that you have not written about on this form? If so, please explain here or on another sheet of paper: I declare that this information is accurate and complete. (Name of Counselee) (Name of Counselee) By: By: (Signature of Parent or Guardian) (Signature of Parent or Guardian) (Printed or typed name) (Printed or typed name) Parent Parent Guardian Guardian First Witness Signature Second Witness Signature Type or Print Name Type or Print Name