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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 ___________
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:
*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:
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).
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.
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:
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:
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: ________________________________________________ |