Biblical Counseling Application

Personal Data Information Form

This form must be completed in full before a counselor is assigned. All information is confidential.
Identification Data
Name

First NameLast Name
Email
example@example.com
Phone Number (Cell)
Please enter a valid phone number.
Phone Number (Home)
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Sex
Birthdate

MonthDayYear
Date
Referred by

Health Information
Rate your health
Height
Weight
Weight changes recently (+-)
List all important present or past illnesses or injuries or handicaps
Date of last medical examination

MonthDayYear
Date
Report
Your physician
Physician's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you presently taking medication?
List medications and dosage
Have you ever used recreational drugs?
List
Have you ever been arrested?
Are you willing to sign a release or information form so that your counselor may write for social, psychiatric, or medical reports?
Have you recently suffered the loss of someone close to you?
If yes, when? Please explain

Education
Last level you completed
List any other training (type or other degrees)

Marriage and Family
Marital Status
Name of Spouse

First NameLast Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (cell)
Please enter a valid phone number.
Spouse's age
Education completed
Spouse's occupation
Date of marriage

MonthDayYear
Date
Ages of you and your spouse when married
How long did you know your spouse before marriage?
Length of steady dating your spouse
Length of engagement
Have you ever been separated?
When? Give brief explanation
Have you or your spouse ever filed for divorce?
When? Give brief explanation
Give brief information about any previous marriages
Children: Names, ages, sex, marital status

Religious Background
Church currently attending
Are you a member?
How often do you attend per month
Are you involved in a Grow Group, Small Group, or Bible Study?
Name of group or study
What church did you attend as a child?
Religious background of spouse or fiancee
Do you consider yourself a religious person?
Do you believe in God?
Do you believe Satan exists?
Have you ever "dabbled" in the "Occult" (seances, devil worship, witchcraft, etc.?
Do you pray to God?
Would you say you are a Christian?
How often do you read the Bible?
Do you have regular devotions?
Explain recent changes in your religious life, if any.

Answer the following questions as completely as possible
What is the problem as you see it?
How long has this been going on?
In what way(s) have you contributed to the problem?
What have you tried to do already to resolve the problem?
Do you feel this is an emergency?
As you see yourself, what kind of person are you? Describe yourself.
What, if anything, do you fear?
What can we do? (What are your expectations in seeking counsel?)
Is there any other information that we should know?

Consent to Biblical Cousneling

Please read and sign below
Our Goal - Our goal in providing Biblical 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 enjoy fully 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. (II Peter 1:3 and Romans 15:4.) Therefore, our counseling is based solely on Scriptural principles ratherthan those of secular psychology or psychiatry.

Not Professional Advice - On accepting Biblical counseling services, it is important for you to realize that our Biblical counselors are not professionals in the medical, psychological, psychiatric or legal fields. If you have significant legal, financial, medical or other technical questions, you should seek advice from independent professionals not associated with Highland Park Baptist Church. 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 Biblical principles. By signing this “Consent to Biblical Counseling,” you agree to hold Highland Park Baptist Church harmless in any and all matters associated with the Biblical advice you have received.

Confidentiality - Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. However, because we are continually training others to be effective counselors, we ask that you agree to allow counselors in training to be present during your sessions. Counselors shall be free to discuss counseling sessions and cases with other HPBC counselors and the pastors of the Highland Park Baptist Church, Southfield, Michigan in order to gain the benefit of additional insight and input.

There are four other situations when it may be necessary for us to share certain information with others: (1) when a counselor is uncertain of how to address a particular problem and needs to seek advice from another pastor or elder in this church; (2) when a counselee attends another church and it is necessary to talk with his or her pastor or elders; (3) when there is a clear indication that someone may be harmed unless we otherwise intervene; or (4) 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 arise between counselor and counselee. In order to make sure that any such conflict will be resolved in a Biblically faithful manner, we require all of our counselees to agree that any dispute that arises with the counselor or with this church as a result of counseling will be settled with mediation within the church according to the principles of Scripture and the authority of this local church.

Having clarified the principles and policies of our Biblical 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.
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Personal Data Information Form

Identification Data

Health Information

Education

Marriage and Family

Religious Background

Answer the following questions as completely as possible

Consent to Biblical Cousneling

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