• VFBCC Intake Form

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  • Sex*
  • Birth Date*
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  • Best Days for Counseling*

  • Education

  • Highest Degree*

  • Health Information

  • Rate Your Health*

  • Weight Change Recently?*
  • Date of Last Physical Exam*
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  • Are You Taking Any Medications?*
  • Have You Ever Had a Severe Emotional Upset?*
  • Have You Ever Been Arrested*
  • Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?*

  • Religious Background

  • Baptized*
  • Do You Consider Yourself a Religious Person?*

  • Do You Believe in God?*

  • Do You Pray to God?*

  • Are You a Born-Again Believer?*

  • Do You Read the Bible?*

  • Do You Have Regular Family Bible Study*

  • Marriage Information

  • Marital Status*
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  • Spouse's Address?*
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  • Is Spouse Willing to Come in for Counseling?*
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  • Spouse's Best Days for Counseling*
  • Date of Marriage*
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  • Have Either of you Filed for Divorce?*
  • When was divorce filed?*
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  • Children Information

  • Child 1 Sex*
  • Child 1 Living*
  • Child 1 Marital Status*

  • Child 1 from a Previous Marriage?*
  • Child 2 Sex*
  • Child 2 Living*
  • Child 2 Marital Status*

  • Child 2 from a Previous Marriage?*
  • Child 3 Sex*
  • Child 3 Living*
  • Child 3 Marital Status*

  • Child 3 from a Previous Marriage?*
  • Child 4 Sex*
  • Child 4 Living*
  • Child 4 Marital Status*

  • Child 4 from a Previous Marriage?*

  • Personality Information

  • Have you ever had any psychotherapy or counseling before?*
  • Mark any of the following words which best describe you now:*

  • Do you find it hard to concentrate?*
  • Are you preoccupied with your current health or well-being?*
  • Are you often fearful?*
  • Are you often anxious?*
  • Have you ever had Hallucinations?*
  • Are you afraid of being in a car?*
  • Do you often feel down or sad?*
  • Do you have problems sleeping?*

  • Background Questionaire

  • Consent to Counseling

  • Our Goal — Our goal in providing Christian counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to fully enjoy his love for you and his plans for your life.

    Biblical Basis — We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of secular psychology or psychiatry. Neither the pastoral nor the lay counselors of this church are trained or licensed as psychotherapists or mental health professionals, nor should they be expected to follow the methods of such specialists.

    Not Professional Advice — Some of our counselors work in professional fields outside the church. When serving as counselors within this church, however, they do not provide the same kind of professional advice and services that they do when they are hired in their professional capacities. Therefore, if you have significant legal, financial, medical or other technical questions, you should seek advice from an independent professional. Our pastoral and lay counselors will be happy to cooperate with such advisors and help you to consider their counsel in the light of relevant scriptural principles.

    Confidentiality — Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. There are five situations, however, when it may be necessary for us to share certain information with others: when the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others, when a counselor is uncertain of how to address a particular problem and needs to seek advice from a pastor or elder in this church; when a counselee attends another church and it is necessary to talk with his or her pastor or elders; when there is a clear indication that someone may be harmed unless others intervene; or when a person persistently refuses to renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (see Proverbs 15:22; 24:11; Matthew 18:15-20). Please be assured that our counselors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible.

    Resolution of Conflicts — On rare occasions a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner, we require all of our counselees to agree that any dispute that arises with a counselor or with this church as a result of counseling will be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure of the Institute for Christian Conciliation; judgment upon an arbitration award may be entered in any court having jurisdiction. (We will be happy to provide you with booklets that explain the Christian conciliation process and describe its benefits and procedures.)

    Having clearly stated the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by him as he helps you to grow in spiritual maturity and prepares you for usefulness in his body. If you have any questions about these guidelines, please talk with a pastor or elder. If these guidelines are acceptable to you, please sign below.

  • Date*
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