2024 Berean Biblical Counseling Personal Data Inventory v24.3.12

Welcome to Berean Biblical Counseling!

In pursuing godly advice and guidance through the process of biblical counseling, you are taking the first steps to finding HOPE. We look forward to getting to know you and humbly serving you by Engaging, Encouraging and Equipping you to grow more like Christ.

Biblical counseling is a one-to-one discipleship relationship, based on the Word of God, where those struggling with sin-related battles and suffering can find answers to their problems. Counsel flows from the sovereignty and authority of God’s Word, centered on the gospel, which provides hope through Christ and His resources. It is all dependent on the Holy Spirit’s power and motivated by the love and compassion of the local church.

The process of change and growth requires a commitment by both you and your counselor. This intake information will help define the problems you are challenged with and what counselor may be best suited to help. If you’re not sure you are ready to fill out the paperwork, or still have questions before you do, we are happy to have an informal consultation meeting with you to help better explain the process.

Also know that in most cases, Berean will have two individuals present during counseling sessions. This includes a trained and experienced biblical counselor, as well as an advocate, who is there to provide additional support and accountability as the relationship advances. Biblical counselors are assigned by the ministry leadership based on availability and expertise. In some cases, there may be a wait based on availability. You and your counselor will establish the meeting times and locations ahead of time. Changes to timing and attendance should be done at least a day in advance. The length of the sessions is typically between 60-90 minutes, but they may vary based on the circumstances as the biblical counselor deems necessary. The number of sessions can also vary depending on the issues at hand.

If you have any questions in filling out the intake information, please email us at biblicalcounseling@bereanlife.org. We look forward to meeting you and serving you in the Lord as we seek to glorify God in every aspect of our lives.

In His Service,

The Berean Biblical Counseling Ministry Team

Personal Data Inventory
Name*

First NameLast Name
Email*
example@example.com
Home phone number

Area CodePhone Number
Cell phone number

Area CodePhone Number
Business phone number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Birth date*

MonthDayYear
Date
Marital status*
Education*
Occupation*
Regular church attender?*

YesNo
Referred by:
Referral's phone number

Area CodePhone Number

Marriage and Family Information

If not applicable, proceed to next section
Spouse name

First NameLast Name
Spouse's email
example@example.com
Spouse's home phone number

Area CodePhone Number
Spouse's cell phone number

Area CodePhone Number
Spouse's business phone number

Area CodePhone Number
Spouse's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's age
Spouse's education
Spouse's religion
Is your spouse willing join you for counseling?

YesNoUncertain
Have you ever been separated?

YesNoUncertain
If yes, from When to when?
Have either of you filed for divorce?

YesNo
If yes, from when to when?
Marriage date?

MonthDayYear
Date
Your age on marriage date?
Spouse's age on marriage date?
How long did you know your spouse before marriage?
Length of steady dating with spouse?
Length of engagement?
Give brief information about any previous marriages:
Number of children?
Name, age, and gender of children? * Note if child is from a previous relationship.
If you were reared by anyone other than your ownparents, briefly explain:

Problem Identification Form
What is the main problem, as you see it? What brings you here? *
What have you done about the main problem? *
What can we do? What are your expectations in coming here? *
As you see yourself, what kind of person are you? Describe yourself. *
Is there any other information we should know? *
What, if anything, do you fear in coming for counseling?*
Past counseling: Who and when to when?
What was the outcome of the past counseling?
Have you ever had psychotherapy or counseling before?

YesNo
If yes, please explain
Are you currently involved in other counseling?*

YesNo
If yes, please explain
Problem Checklist

Please mark all that apply
Abuse (Sexual, physical or verbal)

Not an IssueMildModerateSevere
Anger

Not an IssueMildModerateSevere
Anxiety

Not an IssueMildModerateSevere
Anorexia

Not an IssueMildModerateSevere
Apathy

Not an IssueMildModerateSevere
Bitterness

Not an IssueMildModerateSevere
Communication

Not an IssueMildModerateSevere
Conflict / Fights

Not an IssueMildModerateSevere
Depression

Not an IssueMildModerateSevere
Drugs / Drunkenness

Not an IssueMildModerateSevere
Finances

Not an IssueMildModerateSevere
Guilt

Not an IssueMildModerateSevere
Grief

Not an IssueMildModerateSevere
Homosexuality / Same Sex Attraction

Not an IssueMildModerateSevere
Infidelity

Not an IssueMildModerateSevere
Loneliness

Not an IssueMildModerateSevere
Moodiness

Not an IssueMildModerateSevere
Overwhelmed

Not an IssueMildModerateSevere
Pornography

Not an IssueMildModerateSevere
Rebellion

Not an IssueMildModerateSevere
Self Injury

Not an IssueMildModerateSevere
Sex / Lust

Not an IssueMildModerateSevere
Sleep

Not an IssueMildModerateSevere
Have you or your spouse (if married) had an experience with an unplanned pregnancy in your past?

YesNo
INFORMED CONSENT& HOLD HARMLESS AGREEMENT
1. In Matthew 28:18-20 Jesus gave us the command to make disciples. A disciple is simply a learner and follower of Christ. Biblical counseling at Berean Baptist Church is a ministry in which the Bible is used to mentor people in order that they may become more committed followers, or disciples, of Christ. All mentors are under supervision of the church leaders. This mentoring ministry is neither a business nor a profit-oriented activity. Each counselor serves without any charge or fee. They provides their time and energy as a service to God. If you should desire, donations are accepted to help provide materials that are used in the process.
Initials*
2. The range of problems with which we deal is very wide. It includes broken marriages, parent-child relationships, depression, alcohol and drug abuse, tension, turmoil, anxiety, fear, worry, and any number of other problems resulting in mental and physical immobility.
Initials*
3. The counselor is trained in the use of the Scriptures in counseling settings. They are committed to the position that the Scriptures provide the authoritative rule of faith and standard of conduct. They do not base their knowledge on their own opinions, experience, or concepts of behavior, but seek to marshal the full range of biblical truth into focus on the person's need. In mentoring sessions, they will hold to the essential truths of Scripture without particular theological emphasis on any practice not specifically advocated in the Scriptures. Please note that the counselor is a non-professional spiritual counselor. The counselor is not a professional mental health therapist. Nothing in biblical counseling is designed or intended to be the provision of professional mental health services.
Initials*
4. Confidentiality is respected. A case may be discussed with other counselors, pastors or other professionals, but only to the degree necessary to find further biblical solutions to the problem. All such consultations are conducted with the highest standards of biblical ethics. While confidentiality is respected, information disclosed in counseling settings is not covered by any cleric-penitent privilege, nor shall it be covered by any psychologist-client privilege.

You agree that by signing this Agreement, and by participating in biblical counseling, any disclosure by you of information of a confidential nature will be covered by the following terms. Specifically, you agree that if any disclosure contains any of the following information, the counselor shall be free to disclose the information, as they deem necessary, including disclosing such information to governmental authorities and to other affected persons or entities:

a. A disclosure of child abuse;

b. A disclosure of elder or dependent adult abuse;

c. A disclosure of spousal abuse;

d. A disclosure that you present a serious risk of harm to yourself;

e. A disclosure that you present a serious risk of harm to another person;

f. A disclosure which in the opinion of the counselor or church leaders requires action to protect the participants in biblical counseling, the church itself or any other interest of the church. A disclosure required by a subpoena or other court order from a local, state, or federal agency or court.
Initials*
5. Counselors believe in the total health needs of the person being counseled. Your counselor may recommend that you have a full or specified medical examination. If medical assistance is required, counseling will continue, whenever possible, concurrently.
Initials*
6. Your counselor will use all of their skill in applying biblical principles to help you in whatever problem deprives you of the peace and joy that God has promised to you in His Word. Your counselor will concentrate on two basic principles from God's Word: Hope because in Jesus Christ we have a great high priest who has been tempted in all things, yet without sin. Even though every sin common to man may be tempting you, God has promised that He will not let you be tempted beyond your endurance, but will provide for you the way to escape from sin so that you can endure, (I Corinthians 10:13; Hebrews 4:14-16).

Change because in Christ we can learn how to lay aside the old selfish ways of living and put on the new ways of living in a manner worthy of the Lord, to please Him in all respects, bearing fruit in every good work and increasing in the knowledge of God. (Ephesians 4:20-24; Colossians 1:10)
Initials*
7. Normally, sessions will last about one to one-and-a-half hours each week and will continue for 8 to 10 weeks (though it may go longer). However, if the counselor does not observe definite change in the first few weeks, we will seek to identify the cause of the failure, discuss it with you, and help you to correct it.
Initials*
8. There are certain situations in which your assigned counselor will find it necessary to end your counseling relationship. They include, but are not limited to, a failure to attend scheduled sessions, excessive cancellations, prolonged periods without meeting, incomplete homework or other assignments or a general unwillingness to practice and heed counsel given. On a positive note, official counseling will end when the counselor and counselee have determined that significant growth and change have been achieved.
Initials*
9. Appointments are to be made with the counselor directly. They will be your contact person for any questions or matters requiring immediate or emergency help between sessions. Most questions or matters should be recorded and brought to the next session for discussion. If you are unable to come to the session, please notify the counselor at least 24 hours in advance of the session whenever possible.
Initials*
10. At Berean Baptist Church we regularly train others in the ministry of biblical counseling. Toward that end we seek to provide opportunities for counselors-in-training to observe live counseling sessions. There may be a counselor-in-training present for your session. This counselor-in-training is bound by the same confidentiality agreements as your biblical counselor.
Initials*
11. You will need your Bible and a notebook at all sessions including the first one. Be sure to bring them with you each time. Come with high expectations. You will find hope and encouragement even on your first visit. From then on, with your cooperation, we believe you will find a good and acceptable answer to the difficulty that prompted you to contact us.
Initials*
12. CAUTION - READ CAREFULLY BEFORE SIGNING: In consideration of the offer and provision of Biblical Counseling, you agree to release, waive, discharge and covenant not to sue Berean Baptist Church, its officers, servants, agents and employees, including individual counselors (hereinafter referred to as "releasees") from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, that may be sustained by you, or to any property belonging to you, whether caused by the negligence of the releasees, or otherwise, while participating in biblical counseling.

You further agree to indemnify and save and hold harmless the releasees and each of them, from any loss, liability, damage or costs they may incur due to your participation in Biblical Counseling, whether caused by the negligence of any or all of the releasees, or otherwise. By signing below, you agree that it is your express intent that this Release shall bind the members of your family and spouse, and your heirs, assigns and personal representative, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named releasees.

In signing below, you acknowledge and represent that:

A. You have read the foregoing disclosure and release, understand it, and sign it voluntarily;

B. No oral representation, statements or inducements, apart from the foregoing disclosure and release agreement, have been made;

C. You are at least eighteen (18) years of age and fully competent; and

D. You execute this disclosure and release agreement for full, adequate and complete consideration fully intending to be bound by same.
Signature*

Clear
Should be Empty:

Personal Data Inventory

HEALTH INFORMATION

RELIGIOUS BACKGROUND

Marriage and Family Information

Problem Identification Form

Problem Checklist

INFORMED CONSENT& HOLD HARMLESS AGREEMENT