Welcome to Grace Biblical Counseling Ministry

Transcription

1 BIBLICAL COUNSELING MINISTRY Dear Friend, Welcome to Welcome to (GBCM). We are grateful that you have welcomed us into your life at this time. It is never easy to ask for help. We admire the courage, faith, and humility this first step represents on your part. It is our prayer that God will bless this step and use our time together to build more hope and direction into your life. Our goal at GBCM is to provide the highest quality, Christ-centered counseling to individuals and families who are hurting or confused. This means that we will look through the prism of Scripture to see how your beliefs, values, and priorities are contributing to your struggle, whether it be in your emotions, relationships, or sense of identity. We have found this to be the greatest source of authentic, consistent hope. The next step in the counseling process is to complete the intake forms you are now reading. We have designed them to allow the counseling process to start smoothly. You will need to allow approximately 45 minutes to complete these forms. The counseling forms are designed to (1) help us to get to know you in a comprehensive, holistic, and efficient manner and (2) help you organize your thoughts about your counseling objectives. The following five pages provide your counselor with background on your situation (if you are married, then you and your spouse will both need to complete a set of these forms). Finally, the last three pages contain the policies of GBCM. Please read, initial, and sign these pages. If you have any questions, your counselor will be happy to answer them. Thank you for taking the time to complete these forms. Childcare is not provided, and children are not allowed to sit unattended in the waiting room. If you are unable to make alternative plans for your child for the first appointment and subsequent appointments, then counseling should be postponed until arrangements can be made. Please arrange to be on time to maximize your benefit from counseling. NOTE CONCERNING MEDICATION: If you are taking any prescription medication(s) please do not alter your dose on the day of your appointment. If you have recently begun a new medication, please allow approximately two weeks before scheduling your appointment. NEXT STEP: Your next step is to thoughtfully complete these forms and then either the forms back to counseling@gracebaptistchurch.info, fax them to , or mail them to our church office (3601 Ehlmann Rd., St. Charles, MO 63301). Once we have received your forms, we will contact you to schedule your first session. We are grateful to be able to serve you at this time and to be a part of the journey God has for you. We look forward with a sober anticipation toward playing a role in your progress and hope. In Christ, Jonathan Krawczyk Director of GBCM

2 PERSONAL INFORMATION Date: Name: Gender: Male Female Age: Address: City: Zip: Primary Phone Number(s): May we leave a message here: Yes No Secondary Phone Number(s): May we leave a message here: Yes No Occupation/Employer: Avg. Hours/Week: Birth Date: / / Address: Highest degree(s) earned: School: With Whom Do You Currently Live: (Please check all that apply) Alone Parent(s) Spouse Children Boyfriend Girlfriend Other: Marriage & Family Information: (Please complete if you are married or currently engaged) Name of Spouse (or Fiancé/Fiancée): Age: Address: ( same as above) Phone Number: Occupation/Employer: Avg. Hours/Week: Highest degree(s) earned: School: Is spouse willing to come for counseling? Yes No Uncertain Have you ever been separated? Yes No Currently When/How Long? Date of Marriage: Your ages when married: Husband Wife How long did you know your spouse before marriage? Length of steady dating: Length of engagement: Give brief information* about any previous marriages: Ex-Spouse's Name Year Married Length of Marriage Reason for Divorce # Kids * Other relevant information can be written on the back of this page. Child s Name Age Gender Living At Home Married Special Condition(s) PM/A/MC* M / F Y / N Y / N Y / N M / F Y / N Y / N Y / N M / F Y / N Y / N Y / N M / F Y / N Y / N Y / N * Check this column if child is by previous marriage (PM), adoption (A), or lost to miscarriage (MC).

3 SPIRITUAL / RELIGIOUS INFORMATION Do you consider yourself a religious person? Yes No Church Name: Number of years at church: Pastor s Name: Permission to consult with pastor counselor? Yes No Denominational Preference: Church Attendance: (times per month) Are you a part of a Sunday School class? Yes No Are you a part of a Small Group? Yes No What are you learning through sermons and Bible studies at your church? Please list any ministry involvement: Church attended in childhood: Have you been baptized? Yes No If yes, when? If applicable, what is the religious background of your spouse: Spouse s church attendance: (times per month) Do you and your spouse openly discuss and encourage one another in your faith? Yes No Do you pray to God? Yes No If yes, how often? What do you pray about? Have you received Jesus Christ personally as your Savior? Yes No Uncertain Don t know what you mean How would you define the Gospel and what it means to be a Christian? Do you read the Bible? Yes No If yes, how often? Do you have personal devotions? Yes No If yes, how often? Describe your personal devotions: Do you have family devotions? Yes No If yes, how often? Describe your family devotions: Favorite Christian authors: Please note any recent changes in your spiritual life:

4 HEALTH INFORMATION Have you had counseling before? Yes No Have you seen a psychiatrist before? Yes No Currently Age Duration Counselor / Center Issues(s) / Topic(s) / Diagnosis Your Evaluation of Counseling* * Use back of this page if necessary or if you need more space Approximately how many hours of sleep do you get each night? When do you normally: go to bed? fall asleep? wake up? get out of bed? What do you normally do between going to bed and falling asleep? Describe any recent changes in sleep habits: State of current health: Very good Good Average Declining Other: Date of last medical examination: Results: Current illness, injury, or disability: Are you presently taking any medication? Yes No Prescribing Doctor(s): Medication Dosage Frequency Prescribed for Date began taking Use back of this page if necessary or if you need more space. Have you used drugs for other than medical purposes? Yes No If yes, when? What? Amounts/Dosages: Do you drink alcoholic bevarages? Yes No If yes, how often How much? What type? Describe your eating habits or changes in appetite: Describe your exercise routine: Weight changes: 6 months +/- lbs. 1 Year +/- lbs. 5 Years +/- lbs. Number of non-working hours per week spent: watching television on computer hobbies Please check any of the following physiological symptoms that apply to you: Headaches.. Past Present Difficulty Breathing.. Past Present Rapid Heart Rate.. Past Present Visual Trouble Past Present Tension. Past Present Dizziness.. Past Present Weakness Past Present Fatigue.. Past Present Pain.. Past Present Sleep Trouble. Past Present Change in Appetite.. Past Present Other (on back).. Past Present Indicate how distressed you are by circling a number on the scale below (1 = very little distress; 10 extreme distress):

5 Check any of the following struggles you and/or your family are experiencing at this time: Please rate: leave blank if none; 1 if mild; 2 if moderate; or 3 if severe. Who do you mean by family (mark one)? Home of Origin Spouse & Children Extended Family Abuse, Physical You Family Doubt Salvation You Family Parenting Adult Child Abuse, Sexual... You Family Eating Disorder... You Family. You Family Abuse, Verbal. You Family Empty Nest You Family Peer Pressure... You Family Abuse in Past.. You Family Envy... You Family People Pleasing. You Family Addiction... You Family Fear..... You Family Perfectionism... You Family Adultery.. You Family Financial Management Pornography... You Family Anger.. You Family.... You Family Pre-Marital Sex... You Family Anxiety... You Family Greed... You Family Pride... You Family Apathy.... You Family Grief... You Family Priorities... You Family Bad Memories. You Family Guilt... You Family Procrastination.. You Family Bitterness You Family Homosexuality... You Family Purpose, Lack of... You Family Caring for Parents Humility. You Family Rebellion You Family... You Family Identity... You Family Rejection.. You Family Chronic Pain... You Family Impatience... You Family Relationships... You Family Codependency... You Family Infertility... You Family Respecting Authorities Communication, Affection Insecurity... You Family. You Family. You Family In-Law Conflict... You Family Respecting Parents You Family Communication, Day-to-Day Jealousy.... You Family Respecting Spouse You Family. You Family Judgmental... You Family Same Sex Attraction Communication, Emotions Leadership... You Family.. You Family. You Family Lifestyle Change.. You Family Self-Control.. You Family Communication, Planning Loneliness... You Family Self-Injury... You Family.. You Family Lying... You Family Selfish... You Family Communication, Problem Solving Manipulation... You Family Shame.. You Family. You Family Marital Intimacy.. You Family Social Anxiety. You Family Compulsions... You Family Moodiness... You Family Spiritual Growth.. You Family Depression... You Family On-Line Sins... You Family Submission... You Family Debt... You Family Panic Attacks... You Family Suicidal Thinking.. You Family Discontentment You Family Parenting... You Family Time Management You Family Divorce Recovery You Family Work Unfulfilling.. You Family If you were reared by someone other than your own parents, briefly explain: Number of: Older brothers: Older sisters: Younger brothers: Younger sisters: Step/half: Step/half: Step/half: Step/half: The town I grew up in was: urban suburban small town rural changed frequently My family s financial situation was: poor lower middle middle class upper middle class wealthy Did you have any significant traumatic events as a child? Yes (please describe on back) No Which of the following words best describe your home of origin (check all that apply): Traditional Authoritarian Unpredictable Divorced Lonely Substance Abuse Physical Abuse Verbal Abuse Perfectionist Critical Sexual Abuse Affectionate Affirming Permissive Safe

6 Please complete the following in one or two sentences: In order to understand me My ambition in life is to What really hurts me is I get nervous when I wish I could lose my fear of What I wish I could change about myself is My best childhood memory is My worst childhood memory is My father is/was My mother is/was My biggest regret is My greatest achievement is My role in my current family is For refuge/rest I turn to When life gets too hard I To be happy I need I would do anything for I often wonder why It embarrasses me to I cannot decide 1. Please describe the current problem, as you understand it. 2. What have you done about it (most effective and least effective)? 3. Other than counseling, what help are you seeking? 4. Who referred you to GBCM for help? 5. What are your expectations in coming here? 6. What, if any, are your concerns about coming to counseling? 7. What do you believe you will have to change to see the progress you desire? 8. Is there any other information we should know? Thank you for taking the time to complete these forms. The information you have provided will enable us to better serve you.

7 Policy Review Instructions for Policy Review: After carefully reading each policy please place your initials (beside each dark arrow) in the space provided to indicate your understanding and agreement with each policy. If you have questions, please direct them to your counselor before your initial meeting. If for any reason you are unable to sign these forms, we will be unable to serve you. Not Professional Advice: If you have legal, financial, medical, or other technical questions, you should seek advice from a professional with expertise in those fields. MINSTRY CONTRIBUTION POLICY GBCM will provide counseling, free of charge, as a ministry to help others. Because Grace Baptist Church provides the facilities and the counselors volunteer their time, we can offer the counseling free of charge. Out of respect for our staff, counselees are required to pay a $25 deposit before counseling begins which is forfeited for last minute cancellations. If a counselee leaves counseling or graduates from counseling without a late cancellation, the deposit is returned. Counselees are also expected to pay for materials used to assist them. Counselees are also encouraged that if they are pleased with the counseling they received and would like to have a part in meeting the financial needs of the counseling ministry, they can give a financial gift to GBCM. All contributions are tax deductible. *** Initial here if you understand and agree with this Ministry Contribution Policy: APPOINTMENT CANCELLATION POLICY We do not charge for counseling, but we do charge if you do not show up for an appointment. We require a 24 hour notice if you wish to cancel or are unable to keep an appointment. is not an acceptable form of contact. If you fail to give us a 24 hour notice you will lose the $25 deposit. *** Initial here if you understand and agree with this Appointment Cancellation Policy: PHILOSOPHY OF CARE We are committed to providing a balanced and biblical approach to counseling. Our counseling is based solely on the principles of Scripture and does not employ the teachings or methods of modern psychology or psychiatry. By biblical counseling we mean that your counselor is a Christian with special training and experience in applying the truths of the Bible to life. We believe that the Bible speaks to all of life and to all of its problems, but sometimes it takes careful thought and prayerful wisdom to know how to make those connections. We don t believe that the Bible is simply a how-to book or a recipe book for happiness. We believe that the Bible ultimately points us to a person and a relationship: Jesus Christ as our Savior and Redeemer. We believe that real change comes when people learn to see themselves and their problems in the context of a living, vital relationship with Christ. This does not mean that you must be a Christian to profit from our counseling, although we believe that deep and lasting change is brought about only by God Himself. However, the Bible is never brought to bear in an artificial or heavy-handed way. *** Initial here if you understand and agree with this Philosophy of Care: CONFIDENTIALITY CLAUSE The Director and staff of the (GBCM), understand that confidentiality is an important and vital aspect of the counseling relationship. To that end, GBCM and its representatives agree to carefully guard the information entrusted to them by counselees to the fullest extent possible. Staff members and trainees participating in the GBCM program are expected to protect the information they receive in order to ensure the integrity of the counseling process and the privacy of the counselee. Should a counselor or trainee fail to protect said information, it may become necessary for them to be dismissed from service in the GBCM program.

8 Under certain circumstances, however, it may be necessary to reveal information obtained in the counseling process in order to uphold the principles of Scripture, the standards of Grace Baptist Church, and/or the laws of the state of Missouri. GBCM does not hold to the legal concepts of the priest/penitent, doctor/patient, psychotherapist/patient or counselor/counselee privileges. Situations wherein it may become necessary to reveal otherwise confidential information include, but are not limited to: 1. Where a counselee, although encouraged to renounce a particular sin refuses to do so, it may become necessary to seek the assistance of others in the church to encourage repentance and reconciliation in accordance with the Scriptures (cf. Proverbs 15:22, 24:11; Matthew 18:15-20). In said cases, only such information as is necessary to deal with that particular sin will be revealed. Further, said information will only be revealed to those biblically required to be involved. To that end, it may become necessary to contact the pastor and/or other elders of a counselee s home church. 2. Counselors, uncertain as to how a particular issue should be addressed, may reveal necessary information to and seek assistance from another counselor or pastor. 3. Where a counselee threatens to harm himself/herself or another person, it may become necessary to notify the proper legal authorities, family members, pastor, intended victim, or all of the above. If the counselee makes such threats in the context of a counseling session, the counselor will, upon receiving the information, consult with another GBCM counselor and/or the Director, if such is available, who will work with them to assess the situation and assist in making the appropriate notifications, if necessary. 4. If the counselor is privy to evidence that abuse or some other crime has been or is about to be committed, it may be necessary to reveal such information to the legal authorities. 5. GBCM recognizes that in the course of the loving discipline of their children, Christian parents may employ corporal punishment, in accordance with the teachings of Scripture and, in conformity with those Scriptures, GBCM supports a parent s right to do so. However, if in the course of counseling, the counselor suspects that a minor child has been physically or sexually abused, the counselor will immediately consult with another GBCM counselor and/or the Director who will assist in the assessment of the situation. If it is then suspected that abuse has occurred, the legal authorities will be contacted. If no other counselor is available and a child is in imminent danger of being abused, the counselor will contact the appropriate legal authorities without employing the above consultation process. 6. Observers, including but not limited to, counseling trainees, may sit in on counseling sessions, either to assist in the counseling process or for training purposes. 7. All observers and counselors agree to be bound by this confidentiality agreement and should they be found to be in violation of this agreement understand they face expulsion from the GBCM counseling program by the GBCM Director. *** Initial here if you understand and agree with this Confidentiality Clause: WAIVER OF LIABILITY In seeking counseling from GBCM, you must acknowledge your understanding of the following conditions and further release GBCM, its staff, counselors, and all organizational leadership from any legal liability, claim, or litigation arising from your participation in this voluntary program: 1. Counseling will be provided by ordained ministers (or men and women who are recognized as having exceptional character and leadership qualities by their church) who have had training in biblical counseling. The counseling staff members are not licensed counselors through the state of Missouri; 2. All counseling is provided in accordance with the biblical principles adhered to by GBCM and are not necessarily provided in adherence to any local or national psychological or psychiatric association; 3. No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the above mentioned counselors, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions;

9 4. It is understood by the participant counselee(s) that all complaints and grievances will be heard by the pastors and/or deacons of Grace Baptist Church. If the goal of reconciliation cannot be achieved between the aforementioned parties, then the participant counselee(s) may elect to involve Peacemaker Ministries, Inc., at their expense, for the purpose of mediation or arbitration. *** Initial here if you understand and agree with this Waiver of Liability: CONSENT TO COUNSEL Having read and understood GBCM s Ministry Contribution Policy Appointment Cancellation Policy Philosophy of Care Confidentially Clause Waiver of Liability I, (print name) grant permission for Grace Biblical Counseling Ministries to render counseling services to me and the names listed below (please include the names of those who may be involved in the counseling process): I also understand that GBCM may terminate services for noncompliance with the plan of care and/or agreed upon administrative issues, failure to keep or properly cancel appointments, violent behavior, threats of violence, involvement in criminal behavior, or for other similar issues. * * * * * * * * * * * * * Please sign to indicate the following: 1. You have read the policies in this document; 2. You agree with and understand each of these policies; and, 3. You are enrolling yourself into counseling of your own will. Counselee Signature Counselee Signature (for spouse or second counselee) GBCM Counselor Signature Date Date Date