Counseling Intake Form

Your name *

Email address *

Consents and Agreement

I desire to receive counseling and ministry from Heritage Biblical Counseling Ministries ("HBCM"). I make the following acknowledgements and agreements and give the following consents: *

1. The counseling will be by a counselor who is trained in biblical counseling who may or may not have other certifications or degrees.

2. A basic principle of biblical counseling is that the Bible is sufficient to understand how to live a God-pleasing life, therefore:

- The counseling I/we will receive will be based upon scriptural principles rather than principles of psychology or psychiatry.

- The counseling I/we will receive will be based on the conclusions that the Bible is inerrant and authoritative, and contains God's answers to the issues of life, conduct and relationships.

- The counseling I/we will receive will reflect the counselor's understanding of the Bible and how the principles of scripture apply to the problems, questions or issues involved.

3. Because HBCM is also a training ministry, trainees (i.e. those being trained in biblical counseling) may be present in the counseling sessions and they will abide by the confidentiality statement articulated in #4 below.

4. Counseling at HBCM, including statements made during counseling, shall remain confidential, with the following qualifications and exceptions:

- If necessary, counselors may discuss counseling sessions and cases with other HBCM counselors and the pastors of Heritage Baptist Church in order to gain the benefit of additional insight and input;

- Counselors and pastors shall be entitled to seek a confidential legal opinion or advice from an attorney when it is deemed appropriate and helpful;

- If any HBC policy concerning the reporting of child abuse or child neglect, or the reporting of elder abuse or elder neglect, mandates a report to Child Protective Services or other authorities in compliance with the laws of the State of Pennsylvania, then such report will be made;

- If a suicide risk is indicated, the counselors or pastors may seek necessary help and make whatever reports or disclosures as they deem to be proper and necessary;

- If a counselee indicates an intention to commit a crime, such intention may be reported and disclosed to the proper authorities;

- If the counselee is a member of a local church other than Heritage Baptist Church, and if the pastors of Heritage Baptist Church deem it necessary or helpful to communicate information or facts to the pastor of the counselee's local church, they may do so.

5. Counselees will be asked to pay for resources used in counseling sessions, including items such as booklets and books.

I HAVE READ AND UNDERSTAND THE ABOVE PROVISIONS, AND I HEREBY ACKNOWLEDGE AND AGREE TO ALL OF THE ABOVE TERMS.

Please initial below:

Personal Information

If a question does not apply, please type N/A.

Phone number *

Address *

Place of Business: *

Marital Status: *

Single

Engaged

Married

Separated

Divorced

Widowed

College Major (if applicable):

Other Education or Training (please list):

Rate your current physical health: *

Please check one option.

Good

Average

Declining

Poor

Recent health changes: *

Please specify any recent health changes you've experienced.

List all important past or present illnesses, injuries, or handicaps: *

Date of last medical examination: *

Results of last medical examination: *

Have you ever had a severe emotional upset? *

Yes

Have you ever had a problem with alcohol or drug abuse (prescription or non-prescription)? *

Yes

Have you ever been physically abused as a child or as an adult? *

Yes

Have you ever been sexually molested, either as a child or as an adult? *

Yes

Have you seen a psychologist, psychiatrist, and/or counselor? *

Yes

Are you willing to sign a release of information form so that your counselor may write for helpful social, psychiatric, or medical report? *

Yes

Have you ever been arrested? *

Yes

Have you ever used drugs for other than medical purposes? *

Yes

Are you presently taking any medication? *

Yes

Religious Background

Do you currently attend church? *

Yes

Are you a member of a church? *

Yes

How many times do you attend church per month? *

Church attended in childhood: *

Have you been baptized? *

Yes

Are you saved? *

Yes

Not sure what this means

How often do you read the Bible? *

Explain any significant religious changes in your life, if any: *

How would you describe your personal relationship with Jesus Christ? *

Marriage Information

Note: if never married, check "Not applicable" below and skip to the "Information About Children" section.

Not applicable

Phone number of spouse:

Occupation of spouse:

Place of employment of spouse:

Phone number for spouse's place of employment:

Highest level of education completed by spouse:

Is your spouse willing to come in for counseling?

Yes

Have you ever been separated?

Yes

Have either of you ever filed for divorce?

Yes

Date of this marriage:

Wife's age when married:

Husband's age when married:

How long did you know your spouse before marriage?

Length of steady dating with spouse:

Is this your first marriage?

Yes

Information About Children

How many children do you have, if any?

Please list names, ages, and genders of all children:

Please list which children, if any, are still living in your home:

Please list which children, if any, are by a previous relationship:

What is the main problem, as you see it? What brings you here? *

What have you done about it? *

What can we do? What are your expectations in coming here? *

As you see yourself, what kind of person are you? Describe yourself. *

Is there any other information we should know?

Signature *

By typing my full name, I am signing this form electronically and am acknowledging that I have provided the above information truthfully and to the best of my ability.

Consents and Agreement

Personal Information

Health Information

Religious Background

Marriage Information

Information About Children

Other Basic Info