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CCTC APPLICATION FOR BIBLICAL COUNSELING
For any field that does not apply, please enter "NA" or leave it blank
PERSONAL (Confidential)
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Referred to CCTC by
*
Best time to reach you by phone
*
Please Select
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Gender
*
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Male
Female
Date of birth
*
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Month
-
Day
Year
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Marital status
*
Please Select
Married
Single
Widowed
Education
*
Please Select
High school or GED
Associate degree
Bachelor's degree
Graduate degree
Other
Other education and training (list type and years)
Occupation
Church attending now
Pastor's name
Is your pastor aware that you have contacted CCTC for counseling?
*
Please Select
Yes
No
I don't have a pastor
Church attendance
*
Please Select
Weekly
Monthly
Yearly
Other
Briefly explain your reason for seeking counseling now.
*
When are you available for counseling?
*
9 AM -12 PM
12 - 3 PM
3 - 6 PM
6 - 9 PM
Monday
Tuesday
Wednesday
Thursday
Friday
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HEALTH
Health condition
*
Please Select
Excellent
Good
Fair
Poor
List all important present and past illnesses, injuries, surgeries or disabilities
*
Date of last medical examination
-
Month
-
Day
Year
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List any important information from the last medical examination
List medications you are currently taking
*
List drugs you are using or have used for nonmedical purposes
*
Physician's name
Physician's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List any severe emotional upset you have experienced
Have you received any counseling or psychotherapy?
*
Please Select
Yes
No
List any previous counselors, therapists and the outcome
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MARRIAGE AND FAMILY
Spouse name
First Name
Last Name
Spouse address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse home phone
Please enter a valid phone number.
Spouse mobile phone
Please enter a valid phone number.
Spouse work phone
Please enter a valid phone number.
Spouse email
example@example.com
Spouse occupation
Spouse education
Please Select
High school or GED
Associate degree
Bachelor's degree
Graduate degree
Other
Spouse religious background
Please Select
Christian
Judaism
Hinduism
Muslim
None
Spouse date of birth
-
Month
-
Day
Year
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Spouse reason for seeking counseling
Spouse's health condition
Please Select
Excellent
Good
Fair
Poor
Have either of you ever been separated?
*
Yes
No
If separated, list beginning and ending dates
Have either of you filed for divorce?
*
Yes
No
If divorced, list its date
-
Month
-
Day
Year
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Dates of previous marriage(s) and a brief description of each
Length of time you knew your spouse before marriage
Length of dating with spouse
Length of engagement to your spouse
Marriage date
-
Month
-
Day
Year
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Husband's age when married
Wife's age when married
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CHILDREN
Each counselee is responsible for their own childcare
Child's name, age, sex, education, marital status and whether part of counseling
Child's name, age, sex, education, marital status and whether part of counseling
Child's name, age, sex, education, marital status and whether part of counseling
Child's name, age, sex, education, marital status and whether part of counseling
My spouse or I have successfully completed CCTC courses, Biblical Problem Solving or Building Biblical Relationships
*
Yes
No
If a course listed above has been completed, list the course date and instructor's name
CCTC is a nonprofit ministry that serves people who have problems they cannot handle alone. The range of issues is diverse and includes broken and dysfunctional marriages, parent-child relationships, depression, alcohol and drug abuse, and personal and interpersonal turmoil and distress.
Counselors have been intensively trained in the principles and practices of biblical counseling.
They are not trained psychotherapists or licensed professional counselors, nor do they practice psychological therapy.
The Biblical Counselor maintains that Scripture provides practical, in-depth solutions to every attitude, behavioral and emotional problem. The counselor is committed to the position that Scripture provides the only authoritative rule of faith and conduct for life.
Counselors usually work in teams. Sessions are normally one hour and are conducted by a lead counselor assisted by one other. This allows for greater insight and objectivity in the counseling process and also helps train less experienced counselors. All counselors are under supervision and come to CCTC with the support and recommendation of their pastor or local church.
Confidentiality is respected. What occurs in counseling sessions may be discussed with other counselors or the leadership of your church, but only to the degree necessary to find further biblical solutions to the problems presented. Exceptions to this policy would involve situations where Scripture or Code of Virginia demands otherwise. In either case, the counselee will be informed prior to such disclosure. All such consultation will be conducted in accordance with the highest standards of biblical ethics.
CCTC believes in the total health needs of the counselee. Your counselor or instructor may recommend that you have a full or specified medical examination. The Counseling Coordinator will call to schedule an assessment appointment. The purpose of the appointment is to evaluate your situation and to offer recommendations. Options could include weekly counseling sessions, counseling courses, crisis intervention, and/or referral to another counseling organization.
Please submit a $75 administrative fee which covers your assessment appointment. A donation of $75 is suggested for each additional session following the assessment.
Tuition for CCTC courses described at https://www.cctcinc.org/training is set only to cover costs so that finances will not hinder anyone from enrolling.
If you are experiencing financial difficulty, please refer to the
Financial Resources Checklist
. Please give serious prayerful consideration to the checklist as you determine how you might contribute to the counseling expense.
No one is denied help due to lack of financial resources
.
CCTC’s costs exceed income from counseling and classes. As a nonprofit organization, CCTC depends on support from a variety of sources including the people we serve. This is a biblical means of support for continuing the work of ministry at taught in Galatians 6:6, Matthew 10:5-11, I Corinthians 9:14 and I Timothy 5:18. Upon completion of your counseling or course, recurring support to CCTC is greatly appreciated.
Come with high expectations. We believe that, with your cooperation, the Lord will help you find a good and acceptable answer to the difficulty that prompted you to contact us.
We commit to pray for you and for those involved in your particular situation. Please begin to pray for us as well that we might know how best to serve you.
Click the link below to submit the initial assessment fee.
Square Payments
I submitted the initial assessment fee above.
*
Yes
No
Submitting this electronic form indicates that I have read and understand the above and consent to allow note taking of any counseling sessions conducted by CCTC on my behalf. I understand that my case may be discussed with other counselors at CCTC, other professionals and/or my church leadership, but only to the degree necessary to find further biblical solutions to the problems presented. I understand that any outside consultation will be discussed with me and will be conducted in accordance with the highest standards of biblical ethics. I further agree not to hold CCTC liable for any malady, illness, and/or death, the cause of which may be attributable to the side effects of any prescription or medications which I am currently taking.
*
Yes
No
Name of applicant
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Name of spouse (if applicable)
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Spouse signature (if applicable)
Date application submitted
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