VFBCC Intake Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sex*

FemaleMale

Birth Date*

Date

Age*

Occupation*

Work Phone Number*

Area CodePhone Number

Times of Availability for Counseling?*

:HourMinutesAM/PM Option

to

until :HourMinutesAM/PM Option

Best Days for Counseling*

Referred By:*

First NameLast Name

High School*

Last Year Completed

College/Graduate School*

Years Completed

Highest Degree*

Rate Your Health*

Approximate Weight*

Lbs

Weight Change Recently?*

NoLossGain

Weight Change Amount*

Lbs

List all important present or past illnesses or injuries or handicaps: *

IF none then type in none

Date of Last Physical Exam*

Date

Report of Your Physical Exam*

Your Physician

First NameLast Name

Physicians Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are You Taking Any Medications?*

YesNo

What Medications*

Have You Ever Had a Severe Emotional Upset?*

YesNo

Explain Your Emotional Upset*

Have You Ever Been Arrested*

YesNo

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?*

YesNo

Denominational Preference*

Membership if Any

Church You Attended as a Child

Baptized*

YesNo

Do You Consider Yourself a Religious Person?*

YesNoOther

Do You Believe in God?*

YesNoOther

Do You Pray to God?*

OftenOccasionallyNeverOther

Are You a Born-Again Believer?*

YesNoOther

Do You Read the Bible?*

OftenOccasionallyNeverOther

Do You Have Regular Family Bible Study*

YesNoOther

Explain any recent changes in your spiritual life, if any.

Marital Status*

Name of Spouse*

First NameLast Name

Spouse's Phone Number*

Area CodePhone Number

Spouse's Address?*

Same as Your OwnDifferent Address than Your Own

Spouse's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse's Age*

Spouse's Occupation*

Spouse's Work Phone*

Area CodePhone Number

Spouse's Religion*

Is Spouse Willing to Come in for Counseling?*

YesNo

Spouse's Times of Availability?*

:HourMinutesAM/PM Option

to

until :HourMinutesAM/PM Option

Spouse's Best Days for Counseling*

Date of Marriage*

Date

Your Age When Married*

Years Old

Spouse's Age When Married*

Years Old

How Long did You Know Each Other Before Marriage?*

How Long did You Date Each Other Before Marriage?*

How Long was your Engagement?*

Have Either of you Filed for Divorce?*

YesNo

When was divorce filed?*

Date

Give brief information about any previous marriages if applicable.

How Many Children*

If more than four place the first four on form and then contact the counseling center to give them the rest of the information on the other.

Child 1 Name*

First NameLast Name

Child 1 Age*

Child 1 Sex*

MaleFemale

Child 1 Living*

YesNo

Child 1 Education in Years*

Child 1 Marital Status*

YesNoOther

Child 1 from a Previous Marriage?*

YesNo

Child 2 Name*

First NameLast Name

Child 2 Age*

Child 2 Sex*

MaleFemale

Child 2 Living*

YesNo

Child 2 Education in Years*

Child 2 Marital Status*

YesNoOther

Child 2 from a Previous Marriage?*

YesNo

Child 3 Name*

First NameLast Name

Child 3 Age*

Child 3 Sex*

MaleFemale

Child 3 Living*

YesNo

Child 3 Education in Years*

Child 3 Marital Status*

YesNoOther

Child 3 from a Previous Marriage?*

YesNo

Child 4 Name*

First NameLast Name

Child 4 Age*

Child 4 Sex*

MaleFemale

Child 4 Living*

YesNo

Child 4 Education in Years*

Child 4 Marital Status*

YesNoOther

Child 4 from a Previous Marriage?*

YesNo

If you were reared by anyone other than your parents please explain:

How Many Older Brothers*

How Many Older Sisters*

How Many Younger Brothers*

How Many Younger Sisters*

Have you ever had any psychotherapy or counseling before?*

YesNo

List counselor or therapist and dates:*

What was the outcome/and or diagnoses?*

Mark any of the following words which best describe you now:*

Do you find it hard to concentrate?*

YesNo

Are you preoccupied with your current health or well-being?*

YesNo

Are you often fearful?*

YesNo

Are you often anxious?*

YesNo

Have you ever had Hallucinations?*

YesNo

Are you afraid of being in a car?*

YesNo

Do you often feel down or sad?*

YesNo

Do you have problems sleeping?*

YesNo

1. What is the main problem as you see it? What brings you here?*

2. What have you done about it?*

3. What can we do? What are your expectations in coming here?*

4. As you see yourself, what kind of person are you? Describe yourself.*

5. Is there any other information we should know?*

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.

Signed*

Date*

Date

VFBCC Intake Form

Education

Health Information

Religious Background

Marriage Information

Children Information

Personality Information

Background Questionaire

Consent to Counseling