Personal Data Inventory

Please take the next 30 minutes or so to complete this inventory.

By completing this, it gives your counselor good preliminary information in order to get a “running start” in the early sessions.

The heart of nouthetic counseling is in the fundamental belief that the Bible is completely sufficient to meet all of life’s most difficult circumstances. Thus, our counseling keeps the Bible at the forefront of everything we teach and counsel.

Although our counseling is free, we have four primary requirements for counseling. If you can agree to these, please complete the form below.

You must be teachable
You must be honest
You must do your homework
If able, you must attend Community Bible Church during the time you are being counseled (it is not a requirement to give or serve)

If you have any questions about our counseling ministry, call (352) 229-2060. Our secretary works as a volunteer so if she cannot answer the phone, please leave a message and your call will be returned as quickly as possible.

Today's Date *

Full Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

Occupation *

Employer *

Sex *

Male Female

Birthdate *

Age *

Marital Status *

Married Single Separated Divorced Widowed

Highest Level of Education *

Elementary High School GED College Graduate

Degree *

Other Training (List type and years) *

Hobbies *

Referred to us by *

Referral relationship *

If you were raised by anyone other than your parents, briefly explain *

How many siblings do you have? *

Older brothers

*

Older sisters

*

Younger brothers

*

Younger sisters

Name of Spouse *

First Name Last Name

Spouse Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Spouse Occupation *

Spouse Phone *

Area Code Phone Number

Spouse Age *

Does your spouse know you are coming for counseling? *

Yes No N/A

Have you ever been separated? *

Yes No N/A

If so, when? *

From

*

To

Your ages when married *

Husband

*

Wife

Wedding 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 *

List the information about your children (names, ages, sex, step children) *

Have you dealt with severe emotional struggles in your past? *

Yes No

Have you ever had any therapy or counseling before? *

Yes No

If yes, list counselor or therapist dates *

What was the result of your counseling? Why did you stop counseling? *

Check any of the following words which best describe you now *

Complete this sentence: *

If only

*

then I would be

Rate your health *

Very good Good Average Declining

Approximately how much sleep do you get each night? *

When do you go to sleep at night? *

When do you get up? *

Recent weight changes, if any? *

Do you have chronic medical conditions? List and describe below: *

When is the last time that you have been seen by a doctor for a physical? *

What were the overall results of your most recent medical examination? *

Are you presently taking prescription medications? *

Yes No

Please list the name of the medication, dosage, and what it is for: *

How often do you consume alcohol? *

Daily Weekly Occasionally Never

In the past five years, have you used illegal or excessive prescription drugs? *

Yes No Not sure

Church attended in childhood (if any) *

Childhood Church City *

What church do you now attend (if any)? *

Current Church City *

What is the number of church activities you attend per month? *

Do you desire for us to contact your pastor for background information? *

Yes No

Do you believe in God? *

Yes No Uncertain

Do you pray to God? *

Yes No Uncertain

Are you a Christian? *

Yes No Uncertain

Briefly describe, in your own words, how one becomes a Christian *

Have you come to the place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven? *

Yes No Not sure

How often do you read the Bible? *

Often Occasionally Never

Does your family regularly read the Bible and pray together? *

Often Occasionally Never

Religious background of spouse *

If you died today and God asked you “Why should I let you into my heaven?” What would you say? *

Explain any recent changes in your religious/spiritual life, if any: *

How do you describe the problem(s) that bring you to counseling? *

What do you believe is/are the solution(s) to the problem(s)? *

What have you tried to do about it? *

Best case scenario from today forward, what will your life look like 5 years from now? *

How do you hope counseling might help? (What are your expectations in coming here?) *

What recent event brings you here at this time, if any? *

Is there any other information you think we should know to help you? *

Are you willing to be teachable, honest, do your homework and be in church throughout the counseling process? *

Yes No Uncertain

Uncertain reason: *

Consent to Counsel

The Life Center, A Ministry of Community Bible Church

Ocala, Florida

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 sufficient guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of psychology or psychiatry. Neither the pastoral, nor the lay counselors of this ministry are licensed as psychotherapists or mental health professionals and may or may not have degrees or certifications. All our counselors are under the authority of the elders of Community Bible Church.

Professional Advice:
In the process of biblical counseling there are often times when there is a need for significant advice with regards to legal, medical, financial or other technical areas. In those cases you will be encouraged to seek independent professional counsel. Our pastoral and lay counselors will be happy to cooperate with such advisors and help you consider their counsel in the light of relevant scriptural
principles. Some of our lay counselors may be lawyers, doctors or other professionals, but the counselee understands and agrees that such counselors are not providing advice in those areas during the counseling process.

Fees and Resources:
We want to bless our community by providing these counseling services. Since the counselors volunteer their time, we can offer the counseling free of charge. In order to provide good, helpful resources, we ask, if you are able, to pay for the reading materials you will need (usually around $15/resource). Out of respect for our staff we require a $25 deposit that will be refunded to you should you keep all your appointments or cancel at least 24 hours in advance of your appointment. When you arrive for your first counseling session you will be required to submit this deposit in cash. If you should ever cancel upon less than 24 hours notice, you would forfeit your cancellation fee. You would need to submit another $25.00 before continuing your counseling sessions.

What to Bring:
Please bring with you (one for each person being counseled) a Bible (a literal translation such as NASB, ESV, NIV etc. rather than a paraphrase such as The Living Bible), loose-leaf notebook, paper and pen.

Training Center:
The Life Center, A Ministry of Community Bible Church is also a training center for future counselors. Accordingly, to facilitate both counseling and training, the counselor may have one to two people assisting or observing him/her in each counseling session.

Confidentiality:
Confidentiality is an important aspect of counseling, and we will carefully guard the information you entrust to us. There are situations, however, when it may be necessary for us to share certain information with others. Therefore, you agree that our counselors may share certain information:

1) When a counselor is uncertain how to address a particular problem and needs to seek advice from another pastor, elder or counselor;
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, including you, may be harmed unless others intervene;
4) When required by laws of the State of Florida and the United States of America;
5) When a person persistently refuses to renounce a particular sin, and it becomes necessary to seek assistance of others in the church to encourage repentance and reconciliation (see Matt 18:15-20; Prov 15:22; 24:11).

Also, if you are a member/attender of Community Bible Church, the fact you are receiving counseling may be shared with the Pastor-Teacher to assist him in shepherding the flock.

Be assured that our counselors strongly prefer not to disclose personal information to others, and 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 develop between a counselor and a counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner, we require all of our counselees to agree that any dispute that arises with a counselor or with the church as a result of counseling, will be settled by mediation and, if necessary, legally binding arbitration in accordance
with the Rules of Procedure of the Institute for Christian Conciliation, a division of Peacemaker® Ministries (complete text of the Rules is available at www.Peacemaker.net). Judgment upon arbitration award may be entered in any court having jurisdiction.

The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and expressly waive their right to file a lawsuit in any civil court against one another for such disputes, except to enforce an arbitration decision.

An executed facsimile copy or e-mail delivery of a “.pdf” format data file shall be an acceptable form of acceptance of this Consent.

If you have any questions about these guidelines, please talk with Mike DeGuzman, Teaching Pastor of Community Bible Church (352) 680-0056.

I/WE HAVE READ AND UNDERSTAND THE ABOVE PROVISIONS, AND I/WE UNDERSTAND THEM AND I/WE HEREBY ACKNOWLEDGE AND AGREE TO ALL OF THE ABOVE TERMS, INCLUDING, BUT NOT LIMITED TO, THE CANCELLATION POLICY, WAIVER OF SEEKING REDRESS (LAWSUIT) IN THE CIVIL COURT SYSTEMS, AND AGREEING THAT ANY AND ALL DISPUTES BE RESOLVED THROUGH RESOLUTION AS DETAILED ABOVE.

Signature *

Clear