Date Received _______________ C3 Church Biblical Counseling Intake Form Please return the completed form by email: C3counseling@c3church.com, fax # 919-934-3114 or return it the church office. “All scripture is God-breathed and is useful for teaching, rebuking, correcting and training in righteousness, so that the man of God may be thoroughly equipped for every good work.” -2 Timothy 3:16-17 What IS Biblical Counseling? Renewing of the mind through Scripture. Showing the worthiness of Jesus Christ and His biblical way. Putting off old habits of thinking and acting by the Spirit’s strength. Putting on the likeness of Christ or the fruit of the Spirit in patterns of growth. For the benefit of the counselee and for the glory of God. What Biblical Counseling IS NOT: Biblical Counseling is not Clinical Counseling. No advice of any kind is ever given about medication the counselee may have been prescribed. Biblical Counseling is not a “quick fix”. It requires a commitment and desire for heart change on the part of the counselee. If you have specific legal, financial or clinical issues, you should seek advice from a professional outside of the church. Our lay counselors will be happy to coordinate your care with those individuals. Requirements and Expectations: Instruction must be Biblical; based on Scripture. Not mixed with man’s wisdom. Accurate to the best of the counselor’s ability. Appropriate to the counselee’s problems, spiritual condition and learning style. The counselee is expected to contact the counselor as soon as possible if he/she cannot attend a scheduled appointment. Repeated missed appointments signify a season of unwillingness to change and may result in a break in counseling. The counselee will be expected to have a teachable spirit as evidenced by completion of homework assignments before the next scheduled session. Confidentiality is respected. The counselee can expect confidentiality on the part of the counselor with the exceptions being the chance of harm to self or others or when the need arises for confidential advice from another lay counselor or professional. I have read and understand the above information. I do not hold C3 Church, Pastor Matt Fry, or the counselor responsible for my own behavior or actions. I agree to uphold the requirements and expectations for biblical counseling to the best of my ability. COUNSELEE:______________________Date: ____________COUNSELEE:____________________________ Please print name Signature Counselor:_________________________ Date:_____________Counselor:_____________________________ Please print name Signature Identification Data: Date_____________________ Name___________________________________________________ Cell Phone (_____) __________ Address _________________________________ City _________________ State _____ Zip _________ Occupation______________________________________________ Home Phone (____) __________ Email address _______________________Sex ____Birth Date __________ Age_______ Height _______ Marital Status: Single___ Dating___ Engaged___ Married___ Separated___ Divorced___ Widowed___ Education (last year completed):___________ (grade) _____ Other training (list type and years): ________ ______________________________________________________________________________________ Referred here by _____________________________ Address ___________________________________ City_________________________ State_______ Zip ____________Phone (____) ___________________ Health Information: Rate your health (check): Very Good___ Good___ Average___ Declining___ Other_________ Your approximate weight __________lbs. Weight changes recently: Lost__________ Gained_________ List all important present or past illnesses, injuries, or handicaps: _________________________________ ______________________________________________________________________________________ Date of last medical examination ________________________ Report: ____________________________ ______________________________________________________________________________________ Your Physician ________________________________ Address__________________________________ City_________________________ State_______ Zip ____________Phone (____) ___________________ Are you presently taking medication? Yes___ No ___ What? ___________________________________ Have you ever used drugs for anything other than medicinal purposes? Yes___ No___ What?___________ Do you/ have you used any illegal drugs? Yes___ No ___ If so, what? __________________________________ When? ___________________________________ Have you ever had a severe emotional upset? Yes ____ No ____ Explain: __________________________ ______________________________________________________________________________________ Have you ever been arrested? Yes _____ No ____ Are you willing to sign a release of information for so that your counselor may write for social, psychiatric, or medical reports? Yes_____ No_____ Religious Background: Denominational Preference: _____________________________ Member __________________________ Are you a member of C3 Church? Yes_____ No_____ Are you in a Connect Group? Yes_____ No_____ If so, who is your leader?________________________ Are you serving on any ministry teams? Yes_____ No_____ If so, which ones?_____________________ ______________________________________________________________________________________ Church attendance per month (circle): 0 1 2 3 4 5 6 7 8 9 10+ Church attended in childhood: ____________________________________ Baptized? Yes_____ No_____ Religious background of spouse (if married) __________________________________________________ Do you consider yourself a religious person? Yes _____ No _____ Uncertain _____ Do you believe in God? Yes _____ No _____ Uncertain _____ Do you pray to God? Never _____ Occasionally _____ Often _____ Are you saved? Yes _____ No _____ Not sure what you mean _____ How much do you read your bible? Never _____ Occasionally _____ Often _____ Do you have regular Family devotions? Yes _____ No _____ Explain Recent religious life, if any _________________________________________________________ Personality Information: Have you ever had any psychotherapy or counseling before? Yes _____ No _____ If yes, list counselor or therapist and dates: ___________________________________________________ ______________________________________________________________________________________ What was the outcome? __________________________________________________________________ Circle and of the following words which best describe you now: active ambitions self-confident persistent nervous hardworking impatient impulsive moody often-blue excitable imaginative calm serious easy-going shy good-natured introvert extrovert likable leader quiet hard-boiled submissive self-conscious lonely sensitive other_____________________________________ Have you ever felt people were watching you? Yes_____ No_____ Do people’s faces ever seem distorted? Yes_____ No_____ Do you ever have difficulty distinguishing faces? Yes_____ No_____ Do colors ever seem too bright? Yes_____ No_____ Too dull? Yes_____ No_____ Are you sometimes unable to judge distance? Yes_____ No_____ Have you ever had hallucinations? Yes_____ No_____ Do you have any phobias? Yes_____ No_____ If so, of what? (ie. tight spaces, flying, etc.)__________ ______________________________________________________________________________________ Is your hearing exceptionally good? Yes_____ No_____ Do you have problems sleeping? Yes_____ No_____ Marriage and Family Information: Name of Spouse ________________________________ Address _________________________________ City _______________________________ State_________ Zip__________ Phone (_____) ___________ Phone (_____) __________ Occupation _______________________ Business Phone (_____) __________ Your Spouse’s age _____ Education (in years) ___________________ Religion _____________________ Is your spouse willing to come for counseling? Yes_____ No_____ Uncertain _____ Have you ever been separated from you current spouse? Yes___ No___ When? from _______ to _______ Date of Marriage ______________________ Your Ages when married: Husband________ Wife_______ How long did you know your wife before marriage? ____________________________________________ Length of steady dating with spouse __________________ Length of engagement ___________________ Have either of you ever been divorced? Yes ___ No ___ If so, how long were you married?___________ What year was your divorce? _____________ What were the reasons for the divorce?________________ Information about children: Name Age Sex Living? Marital Education Yes/No Status (in years) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________ *check this column if child is by previous marriage If you were reared by anyone other than your own parents, briefly explain:__________________________ ______________________________________________________________________________________ How many older siblings do you have? brothers__________ sisters__________ How many younger siblings do you have? brothers________ sisters__________ Briefly answer the following questions: 1. What is the main problem, as you see it? What brings you here? 2. What have you done about it? 3. What can we do? What are your expectations in coming here? 4. As you see yourself, what kind of person are you? Describe yourself. 5. Is there any other information we should know?
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