Updated MOBC Counseling Intake Form

Our Goal:
The goal of Biblical Counseling is to help people work through difficulties of life in a way that is pleasing and honoring to the Lord Jesus Christ. The way to accomplish this has been provided in the Bible. Our goal is to help others learn God’s truth and live it in a way that is pleasing to God.

Biblical Basis:
Counseling received at Mt. Olive Baptist Church (MOBC) is religious in nature and is conducted under the authority and leadership of MOBC. We believe that the Bible provides sufficient instruction for all matters of life and faith (cf. 2 Timothy 3:16-17; 2 Peter 1:3-4). Our counseling is based solely on the principles of Scripture and does not use the teaching or methods of modern psychology or psychiatry. Those who receive counsel from MOBC understand this biblical distinction in our counseling and that the counsel received will be based upon the counselor’s understanding of the Holy Scripture.

Counseling Fees:

All counseling provided by MOBC is free of charge.
Resources used during the counseling process are the financial responsibility of those receiving counsel. Resources include books, CD’s, pamphlets, or the like. We accept cash or checks made payable to Mt. Olive Baptist Church.
Cancelation of appointments:
- Cancelations less than six hours prior to the appointment are subject to a $30 fee. Counseling will not resume until the fee is paid.
- Failure to show up for an appointment without sufficient notice will result in a $30 fee. Counseling will not resume until the fee is paid.
- Cancelation fees are set because we have counselors who volunteer a large amount of time in the counseling process. These fees can be easily avoided by simply maintaining clear communication with your counselor well in advance of any potential conflicts or scheduling.

Church Attendance:
As long as you are involved in counseling at MOBC you agree to attend at least one church service or Bible study per week at a Bible teaching church. If you are currently not active in a local church, then we ask that you agree to attend MOBC since the teaching here will match what you receive in counseling. This policy is in place because the more you learn about God, His Word, and His instruction for life, the better equipped you are to respond properly to the situations of life that create challenges.

Confidentiality:
MOBC understands that confidentiality is an important and vital aspect of the counseling process. To that end, MOBC and its representatives agree to carefully guard to the fullest extent possible the information entrusted to them by those seeking counsel. However, there are times when it is necessary to share information with others, for example:

In instances where individuals are recognized as first reporters and have a legal obligation to report crimes to the proper appointed authorities.
When there is clear indication that someone has been harmed, or may be harmed unless others intervene, we will break confidentiality to protect those at harm.
Where a counselee is encouraged to renounce a particular sin but 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 Scripture (cf. Proverbs 15:22, 24:11; Matthew 18:15-20).
When a counselor is uncertain of how to address a particular problem and needs to seek advice from another pastor or counselor in this church.
When a counselee attends another church and the counselor needs to talk with their pastor or elder/leader we will break confidentiality as is needed.

* This field is required.Having clarified 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 your counselor. By checking the box below, you are consenting to receive counsel and acknowledge your understanding and agreement with the MOBC counseling agreement.

Contact Information:

First Name

Last Name

Address

City, State

Zip

Phone Number

Personal Information:

Age

Gender

Education

Marital Status

Occupation

Please list any hobbies

Does your spouse know that you are seeking counseling?

YESNO

Will your spouse be joining you for counseling?

YESNO

Marriage Information:How long have you been married?

Marriage InformationHow would you describe your marriage?

Is this your first marriage?

YESNO

How many times have you been married?

Please enter a number

Briefly describe each previous marriage, including length of each marriage, and how each marriage ended.

Is this your spouse's first marriage?

YESNO

How many times has your spouse been married?

Please enter a number

Briefly describe each previous marriage, including length of each marriage and how each marriage ended.

Is this the first time you and your spouse have been separated?

YESNO

How many times have you been separated?

How long have you been separated from your spouse?

Are you willing to work towards reconciliation with your spouse?

YESNO

Is you spouse willing to work towards reconciliation?

YESNO

How long were you married?

Please describe your marriage and the circumstances that lead to divorce.

Was this your only marriage?

YESNO

How many times have you been married?

Please list prior marriage(s) describing the marriage (s) and the circumstances that lead the marriage to end.

How long were you married before you spouse passed?

Please describe your marriage.

Was this your only marriage?

YESNO

Please list prior marriage(s) describing the marriage (s) and the circumstances that lead to end.

Do you (and/or your spouse) have children? * This field is required.

YESNO

Child 1

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 2

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 3

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 4

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 5

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 6

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 7

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Do you and/or your spouse have other children?

Child 8

Child's name:

Whose Child?

Age of child:

Gender:

Living at home?

Please choose which best describes your relationship . . .

Which of the following best describes your homelife as a child?* This field is required.(You may choose more than one.)

Two Parent Home

Single Parent Home

Loving

Abusive

Other

Which of the following best describes your relationship with your father?* This field is required.

Very Close

Good

Strained

No relationship

Other

Which of the following best describes your relationship with your mother?* This field is required.

Very Close

Good

Strained

No relationship

Other

Do you have any siblings?* This field is required.

YESNO

Which of the following best describes you?

Oldest Child

Middle Child

Youngest Child

Which of the following best describes your relationship with your sibling(s)?

Very Close

Good

Strained

No relationship

Other

Growing up, did you attend church?* This field is required.

YESNO

What was the name of the church you attended as you were growing up?

Do you currently attend church?* This field is required.

YESNO

How often do you attend church?

Weekly

1-2 XMonthly

Every Few Months

Couple Times A Year

What is the name of the church you attend?

Are you a member of the church you attend?

YESNO

What is the name of your pastor?

Do we have your permission to contact your pastor?(Every counseling situation is different and sometimes involving your pastor is beneficial; however, we would inform you prior to contacting your pastor.)

YESNO

Do you believe in God?* This field is required.

YESNO

Do you pray to God?* This field is required.

YESNO

How often do you pray?(More than one answer accepted.)

More than once a day

Once a day

At meals

Regularly

Often

Sometimes

Rarely

Do you read your Bible?* This field is required.

YESNO

How often do you read your Bible?

Daily

Couple times a week

Weekly

Occasionally

Rarely

Are you a Christian?* This field is required.

YESNO

If you were to die today are you sure that you would go to heaven?* This field is required.

YESNO

In response to the previous question, upon what do you base your answer? * This field is required.

Have you ever had a severe emotional upset?* This field is required.

YESNO

Have you ever had any psychotherapy or counseling before?* This field is required.

YESNO

In response to the previous question, please provide a brief description, and rough date(s).

In response to the previous question, how would you describe the outcome?

Very Helpful

Helpful

Somewhat Helpful

Not Helpful At All

Please select any of the following that describe you:* This field is required.Check any of the following words which best describe you now:

Active

Persistent

Ambitious

Anxious

Confident

Hardworking

Impatient

Impulsive

Moody

Often Sad

Excitable

Imaginative

Calm

Serious

Easy Going

Shy

Fearful

Introverted

Extroverted

Likable

Leader

Quiet

Inflexable

Submissive

Sensitive

Self-conscious

Lonely

Bitter

Angry

At anytime have you felt that people were watching you?* This field is required.

YESNO

At anytime have you had difficulty recognizing faces?* This field is required.

YESNO

At anytime have you had difficulty judging distances?* This field is required.

YESNO

At anytime have you had visual hallucinations?* This field is required.

YESNO

At anytime have you had auditory (hearing) hallucinations?* This field is required.

YESNO

Please list any fears that you have.* This field is required.

Have you ever been arrested?* This field is required.

YESNO

In response to the previous question, please provide a short detail of reason and explain if this resulted in incarceration.

How would you rate your overall health?* This field is required.

Great

Good

Average

Poor

Terminal

Other

Have you recently experienced any recent changes to your health?* This field is required.

YESNO

In response to the previous question, give brief description of these changes.

Do you smoke?* This field is required.

YESNO

In response to the previous question, how much?

Do you drink alcohol?* This field is required.

YESNO

In response to the previous question, how much?

Do you take any medications?* This field is required.

YESNO

In response to the previous question, please list medication(s) and reason for medication(s).

Have you ever taken recreational drugs?* This field is required.

YESNO

In response to the previous question, please list type and duration.

On average how many hours of sleep do you get each night?* This field is required.

Please list any past or present medical issues that you think may be important.

1. What issue(s) you are struggling with?* This field is required.

2. What have you done about it?* This field is required.

3. What do you want us to do?* This field is required.(What are your expectations?)

4. What circumstances led you to seek a counselor here at this time?* This field is required.

5. Is there any other information that we should know?* This field is required.

6. How did you hear about us?* This field is required.

Updated MOBC Counseling Intake Form