Counseling Intake Form Logo
  • Dear Friend,

    Welcome to the Biblical Counseling Ministry of Salem Heights Church. We are grateful that you are inviting 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 in the counseling ministry is to make the Gospel paramount by connecting our members and our community friends to the life-transforming power of Jesus Christ. We are confident that through the Scriptures and the power of His Spirit, God has given us everything we need for life and godliness (2 Peter 1:3-4). It is our joy to help real people with real problems using the Bible.

    Our commitment as a church is to offer counseling services to church members and those in the local community. As a church, we are committed to help others glorify God with their thoughts, words, and actions through the community of faith. This is made possible by the redemptive power of Jesus Christ, the conviction and guidance of the Holy Spirit, and the instruction of God’s Word. Your counseling will be biblical, pastoral counseling in which the Scriptures are held as the final authority in all matters. If you are not sure that you will be interested in biblical counseling, you will have the option of attending one or two sessions to discover how biblical counseling may help you.

    The next step in the counseling process is to complete the intake forms that follow. We have designed them to allow the counseling process to start smoothly and to allow us to connect you with the resources that fit your needs. 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. Please allow 30 minutes to complete these forms. Please read through everything carefully and contact us with any questions (503-588-0403 ext 1).

    We are grateful to be able to serve you and look forward to walking with you through God’s agenda for your life.

     

    Dave Hamlin, Tara Cox, & Emily Dempster

    The Salem Heights Biblical Counseling Team

    (503) 588-0403 ext 1

  • Counseling Intake Form

  • Personal Data

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  • Thank you for your interest in counseling at Salem Heights Church. At this time, we have openings on our waiting list for individual counseling for community members. Wait time for community members is 2-4 months.  Our waiting list for marriage counseling for community members remains full. Please check our website as we will update our site as we have availability. We also have a link to other local and online counseling ministries.

    If you have any questions, please contact us at 503-588-0403, ext 1, or by emailing us at counseling@salemheightschurch.org.

    If you would like to be placed on our waiting list, please click "Next" to continue. 

  • Emergency Contact Information:

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  • Marriage & Family Information

    For marriage counseling we ask the both spouses fill out the form separately
  • If Married:

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  • Spiritual/Religious Information

  • Health Information

  • Presenting Issues

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  • Counseling Office Hours

  • We look forward to helping you.  Due to the nature of our ministry and that it is funded with support of generous donations from our community, we do have limited hours.  If this is an emergency, please call 911, or Psychiatric Crisis Center (PCC) - Salem at 503-585-4949.  Once your online submission is received, you will be contacted within 3 business days to schedule an initial intake appointment.

    Our Counseling office hours are Monday-Thursday 9am-2pm.  During this time, we can be reached at 503-588-0403 (ext 1).  Counseling appointments are offered Monday and Wednesday evenings from 5-8pm and Monday-Thursday from 9am-3pm.  We are unable to provide childcare for appointments and children are not allowed to wait in our waiting area.  Thank you for your understanding.  

  • Financial Policy

  • Salem Heights Church is able to offer free biblical counseling because of the generous donations of those who give to our ministry. We do not charge for the counseling services offered, however there is a one-time $35 fee requested to cover all resource materials and provide training to our biblical counselors.

    If our ministry has been a blessing to you and God has given you the means to do so, then your financial gift is most welcome. In such cases, checks should be made out to Salem Heights Church, rather than to a particular pastor or counselor, as a way of joining with our members to proclaim the Gospel throughout Salem and even to the ends of the earth (Matthew 28:18-20). 

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  • Philosophy of Care

  • We are committed to providing a balanced and biblical approach to counseling. By biblical counseling we mean that your counselor is a Christian with special training and experience in applying the truth of the Bible to life. We believe that the Bible speaks to all of life and to all of its problems, but 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 for happiness.

    We are confident that through the Scriptures and the power of His Spirit, God has given us all the instruction necessary for the life and godliness (2 Peter 1:3-4). It is our joy to help real people, with real problems, using the Bible. Your counseling will be biblical, pastoral counseling in which the Scriptures are held as the final authority in all matters. If you are not sure that you will be interested in biblical counseling, you will have the option of attending one or two sessions to discover how biblical counseling may help you.

    Most importantly, we believe that the Bible ultimately points us to a Person - the Lord Jesus Christ. We believe that real change comes when people learn to see themselves and their problems in the context of a loving, 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. Because of this, we do not use the Bible in either a superficial or heavy-handed way.

    When necessary, we will work with your physician or other professionals to ensure you receive the appropriate medical care in conjunction with the counseling services you receive.

    We have found that seeking counsel from multiple sources may lead to conflicting guidance or processes. In order to administer the best care for our counselees, we ask that you pause other forms of counseling while working with our team unless the counselor/ psychiatrist is managing medication.

  • The Biblical Counseling Ministry Team:

     

    Salem Heights Church Biblical Counseling Ministry utilizes the help of both trained lay volunteers and pastors. Our counselors do not know everything about biblical teaching and its application to life; nevertheless, they do know much and will do their utmost to help you. Counselors will honestly tell you if they require additional assistance from another member of the Biblical Counseling Ministry. Please understand that biblical counseling consists of Christians providing scriptural advice and practical application. Yet the counselee is held fully responsible for how he/she implements that advice (James 1:23-25). In addition, our counselors are neither psychologists, nor professional counselors. The counseling team consists of pastors, lay counselors, and trainees under the direction of the church elders who provide guidance and oversight. The staff of Salem Heights Church Biblical Counseling Ministry will supervise the trainees and lay volunteers. Appointments may be recorded and/or a biblical counselor trainee may be present in any counseling session for supervison, training and observation. 

    Your Rights as a Counselee:

    As a counselee, you have the right to discuss outcomes and challenges regarding the counseling and receive an estimate of the predicted length, goals, and outcome of the counseling, as well as alternative options to that counseling. You have the right to ask about and/or refuse any techniques used. You are encouraged to report to an elder/pastor or counseling director if you have any grievances regarding the counseling. You may terminate counseling at any time, but we encourage you to consult with your counselor as to the best way to do so. 

    Not Professional Advice:

    If you have significant legal, financial, medical, or other technical questions, we may help you seek advice from an independent professional in that field. 

    Referral Process:

    We believe in biblical counseling and the future support of the Body of Christ once counseling is completed. However, in the case that progress is not being made, a conflict of interest, or for medical concerns, we do make referrals. With your permission, we will work with your family physician and insurance to help seek medical or professional care if needed.

     

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  • Your Commitment to Counseling

  • We are here to partner with you in your transformation.  For this reason, you are committing to a regular, ongoing series of appointments within a specific amount of time.  Because of the limited availability of our counselors and the high need for counseling in our community, we may not be able to hold your spot if you miss two appointments.  If for some reason you need to cancel your appointment, please communicate with our office as soon as possible. 

    Homework:

    Homework will be given between sessions.  This can range from reading information to taking a practical step in your counseling process.  Please come to your appointment prepared to share what you’ve learned.

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  • Confidentiality Clause

  • Confidentiality is an important aspect of the counseling process. We carefully guard the information you entrust to us to the fullest extent possible. As a church-based counseling ministry, we do not offer absolute confidentiality. There are times when it may be necessary for us to share specific information with others. Examples include but are not limited to matters of church discipline (cf. Matt 18:15 ff.), divorce and separation which may include notifying the pastor/elder of counselee's attending church, criminal activities, and potential harm to self or others. Additionally, when a counselor is uncertain how to address a particular situation, the counselor may consult with another member of the Biblical Counseling Ministry team at Salem Heights Church for the purpose of providing the highest level of care within the ministries of the church. To best care for you, we will work together as a ministry team while keeping the circle of confidentiality as tight as possible.

    There are times when counseling information may be shared outside the church context. Those exceptions would include, but are not limited to the following:

    - Known or suspected abuse of any kind

    - The intent to take criminal actions or violence against another person

    - Credible suicidal thoughts or intentions

    If you are suicidal during the course of your counseling with your counselor, it is crucial that you talk with your counselor about these matters. By signing below, you agree to share any suicidal thoughts or intentions with your counselor at any time they arise, and by phone if they occur in between sessions, and that you will seek medical care if you become suicidal in the course of your counseling.

    In the case of marriage or family counseling, there is limited confidentiality, meaning the confidentiality belongs to the couple and not the individual.

    Confidentiality for counseling at Salem Heights Church is defined by pastor-parishioner privilege because we are a local church and our counselors operate as agents of the church (pastors/ministers) not agents of the state (licensed counselors). This means counseling conversations are inadmissible in the court of law. All counseling forms and notes taken by the counselor are the property of Salem Heights Church Biblical Counseling Ministry. They are protected as confidential and may not be used in court proceedings or in any other way that is not authorized by the Biblical Counseling Ministry Team. If your counseling needs require professional representations in a court setting by a counselor, Salem Heights Church Biblical Counseling will likely not be the best fit for your needs.

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  • Waiver of Liability

  • In seeking counseling from Salem Heights Church Biblical Counseling Ministry, please acknowledge your understanding of the following conditions and further release Salem Heights Church, its elders, staff, counselors, employees, and all ministry team leadership from any legal liability, claim, or litigation arising from your participation in this voluntary program:

    1. Counseling will be provided by pastors or church-trained lay leaders. The counseling staff is not a licensed counseling service through the state of Oregon.

    2. All counseling is provided in accordance with the biblical principles adhered to by Salem Heights Church and is not necessarily provided in adherence to any local or national psychological or psychiatic associations;

    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;

    4. In consideration for receiving any form of counseling from Salem Heights Church, the person receiving the counseling agrees to release and waive any and all claims of any kind against the ministry, the staff, the pastoral/lay encouragers or any participating church, which may arise from, result out of, or be related to conduct or advice given. 

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  • Salem Heights Church Biblical Counseling Policies

  • I understand that Salem Heights Church may terminate services for noncompliance with the agenda of care and/or agreed upon administrative issues, failure to keep or cancel appointments, criminal misconduct, violence, or other similar issues. 

    Having clarified the principles and policies of our counseling ministry, we joyfully anticipate the opportunity to walk with you as Christ enables you to grow in spiritual maturity and usefulness to His body. If you have any questions about these guidelines, please speak with you counselor or call the church office (503-588-0403, ext 1).

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  • Payment

  • Salem Heights Church Biblical Counseling provides free biblical counseling because we never want cost to hinder those in need of support and encouragement.

    Because of this, we rely on the generous donations of those who desire to partner with us in ministry to help with the cost of providing counseling sessions that would normally cost around $65 per session, for a series of 6-8 appointments.

    If you have been blessed and encouraged through the counseling or training offered through Salem Heights Biblical Counseling and desire to give, please consider making a donation to our ministry beyond the $35 resource fee. It is through gifts like these that we are able to continue offering counseling and training to the local church.

    If the $35 resource fee is a hardship for you, please continue to complete and submit your intake form, and then contact the church office (503-588-0403, ext 1).

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