IDENTIFICATION DATA

Name __________________________________ Address _____________________________________

City ___________________________________ State ___________ Zip Code _____________________

Phone_____________________________ Business Phone ____________________________________

Occupation ___________________________________________________________________________

Sex ___________ Date of Birth ___________________ Age __________ Height ____________________

Nationality or Ethnic Background __________________________________________________________

Marital Status: Single ___________ Separated ___________

Going Steady ___________ Divorced ___________

Married ___________ Widowed ___________

Education (circle last year completed);

Grade School 1 2 3 4 5 6 7 8 9 10 11 12

College, 1 2 3 4 5 6+

Other training (list type and years) ___________________________________________________

Referred here by (name) ______________________ (address) __________________________________

_________________________________________________________________

HEALTH INFORMATION

Rate your physical health: Very Good _____ Good _____ Average _____ Declining _____

Other______________________________________________________________

Your approximate weight: ________________ Ibs.

Recent weight changes: Lost ___________ Gained ___________

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

______________________________________________________________________________________

Date of last medical examination __________________ Report: ___________________________________

Physician _____________________________ Address _________________________________________

Have you used drugs for other than medical purposes? Yes ______ No ______

What drug(s)? ____________________________________________________________________

Are you presently taking medication? Yes _____ No _____ What? _________________________________

Prescribing Physician: ______________________ Address ________________________________

Have you ever had a severe emotional upset? Yes _____ No _____

Have you ever had any psychotherapy or counseling? Yes _____ No _____ If yes, list name(s) of counselor(s) and dates: ___________________________________________________________________

(continued on next page)

THIS INFORMA TION WILL BE KEPT IN THE STRICTEST CONFIDENCE ACCORDING TO BIBUCAL GUIDEUNES.

 

Are you willing to sign a release of information form so that your counselor may write for helpful social, psychiatric, or medical reports? Yes _____ No _____

Have you ever been arrested? Yes _____ No _____

RELIGIOUS BACKGROUND

Denominational preference: ______________________________________________________________

Name of the church currently attending: _____________________________________________________

Church attendance per month (circle): 0 1 2 3 4 5 6 7 8 9 10+

Church attendance in childhood: ___________________________________________________________

Have you ever been 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 the Bible? Never _____ Occasionally _____ Often _____

Explain recent changes in your religious life, if any: ____________________________________________

_____________________________________________________________________________________

PERSONALITY INFORMATION

Circle any of the following words which best describe you now:

active ambitious self-confident persistent

nervous hardworking impatient impulsive

moody often-blue excitable imaginative

calm serious easy-going shy

introvert extrovert likable good-natured

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 colors seem too bright? ___________ Too dull? ___________

Are you able to judge distance? Yes _____ No _____

Have you ever had hallucinations? Yes _____ No _____

Are you afraid of being in a car? Yes _____ No _____

What difficulties do you have in hearing (if any)? (continued on next page)

THIS INFORMATlON WILL BE KEPT IN THE STRICTEST CONFIDENCE ACCORDING TO BIBUCAL GUIDEUNES.

 

MARRIAGE INFORMATION (If never married, check _____ and omit this section)

Name of spouse ______________________________ Address _____________________________

____________________________________________ Phone ______________________________

Business Phone ____________________Occupation _____________________________________

Is spouse willing to come for counseling? Yes _____ No _____ Uncertain ______

Have you ever been separated? Yes _____ No _____

Have either of you ever filed for divorce? Yes _____ No _____ If so, when? ____________________

Date of this marriage: ________________________________

Your ages when married: Husband ___________ Wife ___________

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: ______________________________________

________________________________________________________________________________

Broken by divorce: ___________ Death ___________

Information about children:

pm*

Name

Age

Sex

Living? yes/no

Education – years

Marital Status

*Check this column if child is by previous marriage.

Your spouse's age ___________ Education (years) ___________ Religion______________________

PARENTAL FAMILY HISTORY

If you were reared by anyone other than your own parents, briefly explain: ___________________________

______________________________________________________________________________________

Answer this section describing your own parents or parent substitute:

Still living? (yes/no) Father ___________ Mother ___________

Religious affiliation: Father ______________________ Mother ______________________

Church attendance per month: Father 1 2 3 4 Mother 1 2 3 4

(continued on next page)

THIS INFORMATION WILL BE KEPT IN THE STRICTEST CONFIDENCE ACCORDING TO BIBLICAL GUIDELINES.

 

Occupation: Father ______________________ Mother ______________________

Are your parents still living together? Yes _____ No _____

If not, cause of separation:______________________________________________________________

When separated: _____________________________________________________________________

Rate your parents' marriage:

Unhappy ___________ Average ___________ Happy ___________ Very Happy ___________

As a child, did you feel closest to your: Father ___________ Mother ___________ Another ___________

Rate your childhood life:

Unhappy ___________ Average ___________ Happy ___________ Very Happy ___________

How many brothers and sisters do you have? _______________________________________________

How many older brothers and sisters do you have? Brothers ___________ Sisters ___________

THIS INFORMATION WILL BE KEPT IN THE STRICTEST CONFIDENCE ACCORDING TO BIBUCAL GUIDEUNES.

 

Name _________________________________

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?

6. Please list previous-counseling you have had and "approximate-'dates, including

hospitalizations.

7. Please list any medications you are presently taking, purpose of each medication, and

dosage.

 

Counseling Waiver of Confidentiality

Wheelersburg Baptist Church

Statement about Counseling: At the heart of our counseling ministry at Wheelersburg Baptist Church is the conviction that the Scriptures are authoritative and sufficient. The Bible is the Word of God, and is the foundation for what we believe concerning such key areas as God, man, sin, man's relationship with God, and man's relationships with his fellow man (II Timothy 3:16-17; Psalm 19:7-11). We believe that the gospel of Jesus Christ is the message which reveals how sinful people can be reconciled to their Creator through the Person and Work of Jesus Christ. All ministry in the church, including the ministry of counseling, is designed to help people experience a meaningful relationship with Jesus Christ. Stated concisely in Colossians 1:28-29, our aim is as follows: "We proclaim Him (Christ), admonishing and teaching everyone with all wisdom, so that we may present everyone perfect in Christ, striving according to His working which works in us mightily."

Counseling Waiver:

I, the undersigned, hereby understand and acknowledge that I have been advised to my satisfaction concerning the following issues about receiving counseling and spiritual guidance at Wheelersburg Baptist Church:

  1. 1. All of the counseling provided by the church is biblically based rather than

psychologically based. As such, the type of counseling I will receive is not clinical

counseling, but biblical and spiritual counseling (the essence of which is

summarized above).

  1. 2. I recognize that all people have strengths and limitations when it comes to

helping others. Thus, I understand that it may become necessary at some point

for the church staff to refer me to another counselor/discipler, or to a

professionally trained counselor, who is more specifically qualified to provide the

help I need.

  1. 3. I understand that the church staff is committed to purity. This means (based on

Titus 2) that spiritually mature men are to counsel men, and spiritually mature

women are to counsel women. I am aware that in situations where this is not

possible, the following parameters will be followed:

    1. a. No counseling of the opposite sex shall take place without the presence

of another person in the building.

    1. b. Individual counseling of the opposite sex shall be limited to three

sessions. After the third session, if further help is needed, it must be

approved by the deacon board, with specific parameters stated.

  1. 4. While a degree of confidentiality exists with the particular pastor with whom I

seek counseling and the church staff, I recognize that only limited rights of

confidentiality exist within the laws of the, State of Ohio. I am aware of the

following:

 

    1. a. I understand that my pastor will keep records of our counseling sessions

which will be held confidential.

    1. b. I understand that there are situations in which the law requires my pastor

to divulge what has been said to him in confidence. I realize that certain information revealed in the counseling process may need to be divulged at some future date under state law.

c. I understand that the pastor will seek to consult with me first regarding

matters where disclosure is necessary.

  1. 5. The church staff and the particular pastor from whom I receive counseling, and

any volunteer to whom he refers me to further assist in spiritual guidance, shall

not be liable under any circumstances, and I hereby waive all rights against the church, its staff, the particular pastor from whom I seek help, and any volunteer as mentioned, for any claims and damages arising directly or indirectly from any physical, emotional, or mental illness or psychological problem I now have or may develop in the future.

  1. 6. Should a dispute arise between myself and my counselor (or any volunteer to

whom he refers me), I will submit the controversy to Christian arbitration rather

than pursuing legal court action (1 Corinthians 6: 1-6).

Signed: ______________________________________________

Date: ________________________________________________