Counseling Form 2 – Jacksonville Bible Church

Name

Address

Best Contact Phone #

Birthdate

Age

Education [last year or degree completed]:

Employer

Job Title

Years Employed

Emergency Contact

Have you ever been arrested? If so, please briefly explain:

Marital Status

How long have you been married/dating?

Name of significant other:

Age of significant other:

Have you ever been separated from your present significant other? If so, please explain:

Have either of you ever broken-off this relationship and then restarted it? If so, please explain

Have either of you ever filed for divorce?

How long did you date prior to marriage OR how long have you dated this person?

Is your significant other willing to come for counseling? If not, please explain:

Is he/she in favor of your coming? If not, please explain:

Is your significant other employed? If so, where and for how long?

Number of previous marriages by significant other (if applicable):

Are your parents living?

Where do they live? (General Location)

Briefly describe your relationship to your father:

Briefly describe your relationship to your mother:

Do you have siblings? If so, how many:

Your sibling order:

When you were growing up, did you live with anyone other than your parents?

Do you have children?

Please list your children below, including their NAME, AGE, GENDER, whether or no they are ADOPTED, and whether or not they are from a PREVIOUS MARRIAGE. An example is included:

Do you believe in God?

Would you call yourself a Christian?

Have you been baptized?

Denominational Preference:

Briefly describe your devotional life (ex. Bible reading, prayer, book studies):

Church presently attending:

Are you a member?

How often do you attend church?

How are you involved within the church?

Briefly explain any recent changes in your spiritual life:

Briefly describe your overall health:

When was your last medical exam:

Name of Physician & Office:

Do you have any chronic conditions (illnesses, injuries, or handicaps)?

How much alcohol do you consume daily?

How much coffee/tea do you consume daily?

How many soft drinks do you consume daily?

How much water do you consume daily?

How many hours of sleep do you average each night?

Is this sleep restful?

Have you ever had a severe emotional upset?

Have you or others noticed any recent changes in your personality (ex: anger, mood swings, withdrawal), thinking, memory, or work habits?

Check the following words that you think best describe you:

"Active" "Ambitious" "Self-Confident" "Persistent" "Nervous" "Hardworking" "Impatient" "Impulsive" "Moody" "Often-blue" "Excitable" "Imaginative" "Calm" "Serious" "Easy-going" "Shy" "Introvert" "Good-natured" "Extrovert" "Likeable" "Leader" "Quiet" "Headstrong" "Lonely" "Submissive" "Self-Conscious" "Sensitive"]

Have you ever seen a psychiatrist or counselor?

Are you currently on any medications?

Please list the medications you are on below including their NAMES, DOSAGES, and PURPOSES. An example is included:

What problem are you having (what brings you here)?

What have you done about this problem?

What are your expectations from counseling?

Is there any other information we should know?

Our Goal: The goal of Biblical Counseling is to help people work through the difficulties of life in a way that will be pleasing and honoring to the Lord Jesus Christ. We are here to help others learn truth so that they may live in accordance with truth.

Counseling Provided and Fees: We are a ministry of Jacksonville Bible Church, a church plant of Southern View Chapel. We provide counseling free of charge because we believe this is what the Bible teaches. The undersigned counselee will receive Biblically based counseling from a qualified counselor at no cost. While counseling is free we do need to charge for most resources used during the counseling process. These charges will mostly consist of books, pamphlets, CD’s or the like. Payment for these materials will be due on the day they are issued. We accept checks or cash, no credit or debit cards. Checks should be made out to Jacksonville Bible Church.

Cancelation Policy: We do not charge for counseling, but we do charge for cancelations made less than six hours prior to the appointment, or if you fail to show up for an appointment. If either of these situations occurs, we will not resume counseling until we receive either a cash payment or a check from you for $30. We have put this policy in place because we have counselors who travel long distances in order to volunteer their time and we do not want to waste their valuable time. You may avoid this charge by simply changing your appointment as soon as you know that you will not be able to keep it or maintaining clear communication with your counselor well in advance of any potential conflicts of scheduling.

Biblical Basis: Counseling received from JBCC is religious in nature and is conducted under the authority and leadership of Southern View Chapel. We believe the Bible provides sufficient guidance for all matters of life and faith (cf. 2 Timothy 3:16-17, 2 Peter 1:3-4). Our counseling is based solely on the principles of Scripture and does not use the teachings or methods of modern psychology or psychiatry. The counseling you receive will be based upon your counselor’s understanding of the Holy Scripture.

Confidentiality: We view confidentiality as a vital element in the counseling process. We strive for the highest integrity concerning confidentiality and have developed a policy that addresses this issue specifically. The Jacksonville Biblical Counseling Center Confidentiality Policy is attached to this form and is to be read, signed, and turned in before counseling begins.

Church Attendance: As long as you are receiving counseling at JBCC you agree to attend at least one church service or bible study at a Bible teaching church. If you are currently not active in a local church, then we strongly recommend you attend Jacksonville Bible Church since the teaching here will match what you receive in counseling. This policy is in place because the more you are learning about God, His Word, and His instructions for life, the better equipped you will be to respond properly to the situations of life that are creating trouble for you. Your counselor will review any specific questions related to this policy. We strongly recommend that you take notes during the service you attend so that you will be able to recall points of importance in that message. Counselors will inquire about services attended and some of the highlights that you gleaned from the service.

Conflict Resolution: On rare occasions a conflict may develop between a counselor and a counselee. The Bible commands that Christians make every effort to live in peace and to resolve disputes with each other in private or within the Church instead of involving the secular courts (cf. 1 Corinthians 6:1- 8). In keeping with obedience to Scripture we require all counselees, whether professing to be Christian or not, to agree to follow these procedures in the event of a conflict with Southern View Chapel, Jacksonville Biblical Counseling Center, or any of the counselors associated with this ministry. By initialing below, I agree that any claim or dispute arising from or related to this agreement shall be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker® Ministries. Judgment upon an arbitration decision may be entered in any court otherwise 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. Copies of the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation are available upon request and more information can be found at www.peacemaker.net/icc.

If you have any questions about these guidelines please speak with your counselor. Your signature below indicates your informed consent to these guidelines.

At the top of the page you will see a link to our confidentiality policy. You must read that policy before completing this form. Once you have read it, please sign and date below.