Biblical Counseling by mD08AE

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									                                                                    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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