BMBC Counseling Ministry Intake Questionnaire

BMBC Counseling Ministry Intake Questionnaire
Thank you for reaching out to the BMBC Counseling Ministry. This referral form is designed to help us understand how the BMBC Counseling Ministry can be of help to you at this time. We offer members of Broadview Missionary Baptist Church, 1-3 sessions to help with support and current concerns, in addition, we provide referrals to professional counseling services if needed. We will help you get connected with other resources in the local community if needed. We do not offer long-term counseling. Our counseling ministry consists of a psychologist, licensed counselors, and lay volunteers.

After you complete the confidential intake questionnaire, one of our counseling team members will reach out to you to set up either a virtual or in-person.
Personal Information
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
MaleFemale
TelephoneEmail
Marital/Family Information
YesNo
SingleMarriedDivorcedWidowedOther
YesNo
Seeking Services
Your Reason for Seeking Counseling?*
AnxietyDepressionRelationship issuesGrief/LossAddictionLife transitionsSpiritual ConcernsOther
How long have you been experiencing these issues?*
YesNo
If Yes, please provide details (when, where, duration,):
YesNo
Goals for Counseling
What do you hope to achieve through counseling?*
Additional Information - Please provide any additional information you think might be helpful for your counselor to know:
Consent for Counseling
Confidentiality
All information shared during counseling sessions is confidential and protected by law. This means that your counselor will not share your information without your written consent, except in specific situations required by law, as outlined below:
- If you express intent to harm yourself (suicidal thoughts or behaviors).
- If you express intent to harm someone else (homicidal threats or actions).
- If there is suspicion or disclosure of abuse or neglect involving a minor, elderly, or vulnerable adult..
Limits to Confidentiality
In cases where confidentiality must be broken due to the reasons above, every effort will be made to ensure your safety and the safety of others while respecting your privacy as much as possible.
I, Full Name* understand that this counseling is provided in a church setting, and my counselor may incorporate faith-based practices in sessions. I agree to participate voluntarily and understand that I may choose not to answer certain questions if I feel uncomfortable.
Signature*

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Date*

MonthDayYear
Date
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BMBC Counseling Ministry Intake Questionnaire

Personal Information

Marital/Family Information

Seeking Services

Goals for Counseling

Consent for Counseling