Redemption Biblical Counseling Intake Form

Full Name*

First NameLast Name

What is your age?*

Gender*

MaleFemale

Contact Number*

Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?*

In the past week, have you had thoughts about harming yourself?*

YesNo

Do you feel safe at home?*

YesNo

Emergency Contact (Name)*

First NameLast Name

Emergency Contact (Phone Number)*

Please enter a valid phone number.

Name of the Church You Attend*

How Long Have You Attended?*

How many times per month do you attend church?*

Do your church leaders support the idea of you being counseled by RBC?*

YesNoHaven't AskedI don't know any of my church leaders

RBC believes that our counsel should not supersede your own pastor's care and responsibility. May we contact your pastor regarding your situation?*

YesNo

Pastor's Name*

Pastor's Number or Email

If you have not asked your pastor or church leader for counsel prior to reaching out to RBC, please explain why below:

Current Marital Status

Does your spouse or significant other know that you are seeking counsel?*

YesNoN/A

Do you have children?*

YesNo

Gender and Ages of Children:*

Education

School

Employer

Job Title

Briefly describe your overall physical health:*

List any current medications and dosage:*

Have you used drugs for recreational purposes within the last 5 years?*

YesNo

Have you ever been arrested?*

YesNo

Have you ever had what you could consider to be a severe emotional upset?*

YesNo

How often do you drink alcoholic beverages?*

Have you ever seen a therapist or counselor in the past?*

YesNo

If yes, name and location:

What is the problem or concern that brings you for counseling?*

What attempts have you already made to resolve this problem or concern?*

What are your expectations from counseling?*

Which of the following BEST describes why you are seeking counseling? (please select all that apply)*

Please give some days of the week and times that would potentially work for you for counseling? (Ex. Monday mornings before 9a, Tuesday evening, any evening except Friday, etc. Or, just put "flexible.")*

Do you believe in God?*

YesNoUnsure

How often do you pray?*

NeverSeldomSometimesOften

How often do you read your Bible?*

How often do you spend time with Christian friends?*

Don't have anyRarelySometimesOften

What is the Gospel?*

How would you define a Christian?*

Do you believe the Bible has the authority to tell you how to live?*

YesNoUnsure

Do you believe the Bible is free from error?*

YesNoUnsure

What sins or temptations do you struggle with most?*

How do you handle the sin in your life?*

How do you promote your spiritual growth?*

What changes would you like your spouse or significant other to make?*

Is there anything else we should know?*

OVERVIEW OF OUR BIBLICAL COUNSELING MINISTRY

The Biblical Counseling Ministry of Redemption City Church is a non-profit organization. The purpose of this particular ministry is to provide biblical counseling services for you as a counselee, free of charge. If anyone feels led to give an offering of thanks for the help received, you may give a donation to the church on the church website.

All counseling will be provided by volunteer lay counselors and not licensed professionals. Therefore, as “biblical” counselors, the goal of our counseling is to help you gain insight into your problem and life, yet help you understand your problem in light of God’s Word and His purpose for your life. The ultimate goal of our counseling is to help you grow in your faith, knowledge, and love for Jesus Christ, His church, and to help you be conformed to His likeness.

BIBLICAL BASIS
Because we believe that the Bible to be the very Word of God to man concerning faith and life, the principles used in our counseling will be based upon Scripture and not necessarily in adherence with any psychological or psychiatric association. A foundation to our counseling is our belief that God has specifically created mankind in His own image and for the purpose of His own glory. Therefore, we believe that, in order to fully address the root of the problems that our counselees face, we must help them apply God’s Word to their lives.

CONFIDENTIALITY
We are often asked whether Redemption Biblical Counseling promises total confidentiality, in other words, that no one else will ever know what is being shared during a counseling session.

We are discreet but not confidential. The concept of total confidentiality is not biblical; however, information regarding a counselee/disciple will be handled with a high level of discretion. Discerning how to share information is an important aspect of the counseling relationship and we will carefully guard any information entrusted to us.

However, Hebrews 13:17 makes it clear that the leaders of the church, not the counselors, have the responsibility for caring for the souls of the church. Because of this, the appropriate staff and/or elders will be made aware of your situation. There are three other situations whereby we may be legally or biblically obligated to share certain information with others:

When there is a clear indication of harm to you or someone else
When there is evidence or reasonable suspicion of abuse against a minor child, elderly person, or dependent adult
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 5:22; 24:11, Matthew 18:15-20)

As part of our mission to train and equip others in biblical counseling, we may have counselor in training participate in the counseling with us. These individuals will abide by the same standards outlined above. We would discuss and get approval from you before allowing a counselor in training to sit in on a session with you.

DISTINCTIVES OF BIBLICAL COUNSELING

The church is called to minister to the whole person within the Body of Christ.
We believe that a personal, vital knowledge of Jesus Christ is essential to salvation and is the foundation of all true biblical counseling. As such, we are committed to a presentation of the gospel to those who seek counseling and are not believers in Jesus Christ.
The main thrust of biblical counseling involves:
- Identifying the core issues
- Identifying and establishing a spiritual mindset
- A four step process to bring about changes from 2 Timothy 3:16
  - Teaching what the Bible says about the issues
  - Conviction of the necessity for the changes
  - Correction of the things that need to be done to create the change
  - Training via homework and accountability that leads to God-honoring habits
The Word of God and its practical application functions as the counselor’s primary tool. As such, we believe the Bible is the only and absolute authority in our lives today.
The work of the person of the Holy Spirit is an integral part of the methodology and philosophy of biblical counseling. The Holy Spirit works to effect change through the Christian’s new identity in Christ and a careful study of and devotion to the Word.
The Word of God is a therapeutic tool as well as a theological one. Thus, it can be used to heal emotional/spiritual issues.
The Scriptures provide the basic standard for every area of life. As such, its system of ethics pertains to any culture and contemporary situation. Biblical counselors, therefore, possess an ethic for both right and wrong thinking and behavior.

PROCEDURES

We begin on time and are not held to a clock.
Everyone stays for the entire session and faces all the issues brought up. Nobody gets up and leaves just because the topic is uncomfortable.
Everyone speaks for him/herself.
Everyone has a chance to be fully heard. We will not interrupt another individual (counselor or counselee) while they are speaking.
We will not ignore the nonverbal or body messages that are emitted, but will deal with them openly as they occur.
The counselor will not take sides.
The time spent together is for the purpose of working on the concerns of persons in the session, not for playing games, making personal points or diversion.
Everyone gets an opportunity to define the current problems and suggest realistic solutions. At least one positive action step is desired from each person.
Homework is an essential part of biblical counseling. Each counselee will be expected to complete his/her assignment prior to each session.
We will deal mainly with the here-and-now, not getting bogged down in the past and in blaming others.
We will confront and deal with each other as honestly and objectively as we possibly can.
There will be no retribution, retaliation, or grudges over what is said in the session. Statements made in the sessions are not to be repeated elsewhere.
There will be no physical violence or threats of violence.
We will operate on the premise that God’s Word has the solution to our problems and seek to be obedient to it over and against our own conclusions.

Note: Due to the increasing need for our counseling services, we ask that you cancel your appointment at least two days in advance in order that we can offer the time to someone on the waiting list. Having multiple cancellations without prior notice may forfeit future sessions.

INFORMED CONSENT AGREEMENT/WAIVER:

As a counselee, having sought biblical counseling from Redemption Biblical Counseling of Redemption City Church, I hereby acknowledge my understanding of the “Policies” (enclosed) of the Biblical Counseling Ministry of this church, and that all these guidelines are acceptable to me. As such, by signing below I do hereby waive any right to pursue legal action against Redemption Biblical Counseling and Redemption City Church, its pastors, agents, employees and lay counselors from any liability (claim or litigation) whatsoever arising from my participation in this ministry.

I understand that the counseling staff of the ministry of Redemption Biblical Counseling are not state licensed under Minnesota statues, and are not psychologists or psychiatrists. I further understand that the pastors of Redemption City Church are not state licensed under Minnesota statues, and are not psychologists or a psychiatrists.

(Each individual counselee must TYPE NAME and SIGN Below.)*

Full Name*

First NameLast Name

Signature*

Counseling Request Form

Standard Safety Questions

Church

Family Relationships

Education and Career

Health

Counseling Questions

Spiritual Questions

Biblical Counseling Policies and Procedures