Personal Data Intake Form
FaithChapelChristianCenter
Counseling Ministry
Personal Data Intake Form
Welcome to the Christian Counseling Department of Faith Chapel Christian Center where we seek to offer biblically based, Christ-centered, counseling/guidance addressing many common issues of life. Our team consists of volunteer lay counselors, staff ministers, and staff counselors who have been called into the helping ministry of biblical counseling and guidance.
Qualifications of counselors: Our staff and volunteerChristian Counselors have years of experience ministering to the personal needs of individuals. Because of the biblical and spiritual nature of this type of ministry we train our staff for the ministry of biblical counseling and guidance. The lay counselors, staff counselors and ministers do not necessarily possess professional licenses or certifications issued by the State of Alabama. No staff, paid or volunteer, of the Christian Counseling Department will render any legal or medical opinions or advice.
Our Approach: The Christian Counseling Department employs a method of biblical counseling and guidance utilizing spiritual/biblical principles. In this kind of discipleship process, the Holy Spirit, not the counselor, is the agent of individual change. Our goal is to present God’s plan for victory in the midst of one’s circumstances.
Limitations of Confidentiality: It is understood (and agreed) that all statements, whether written or verbal, are of a confidential nature and ethically cannot be disclosed without written consent. The following exceptions will result in confidentiality being waived:
1. We reserve the right to report child abuse or suspicion of child abuse of any type to the proper authorities and/or the right to cause a report of child abuse to occur.
2. We reserve the right to disclose to the appropriate person, agency or civil authorities any harm that a person may attempt or desire to do to one’s self or to others.
3. To insure the highest quality discipleship process, as a rule your counselor/lay counselor will consult with their supervisor regarding your sessions(s).
4. We reserve the right to consult with other professionals regarding your sessions, upon written consent.
Resolution of Disagreements: If a dispute should arise between the person receiving ministry and the Lay counselor, staff counselors and minister regarding the counseling session, one should bring this dispute to the attention of the Christian Counseling Department Manager and/or the Care Department Director.
Waiver of Liability: In consideration for receiving biblical counseling and guidance from the Christian Counseling Department, the person receiving counseling agrees to release and waive any and all claims of any kind against the lay counselor, staff counselor, minister or the church, which may arise from, result out of, or be related to their counsel or conduct.
Fees: Members of FaithChapelChristianCenter and non-members of the community do not pay for the services of biblical counseling/guidance.
Late Policy: Counselees more than 15 minutes late to their scheduled appointment will be asked to re-schedule. It is to the counselee’s advantage to be timely in order to receive the full benefit of the scheduled appointment.
Cancellations or Reschedules: In the event you need to reschedule or cancel an appointment we ask that you call 24 hours in advance. This allows us to reschedule others who are waiting. As a courtesy to the counselee, the counselor will make a call within 48 hrs of the appointment, reminding the counselee of their appointment. The call will be made to the number given by the counselee. The counselor will not leave a message concerning the nature of the call, on an answering machine or to anyone other than the said counselee.
Session Length: Counseleesare provided a maximum of four (4) sessions unless other arrangements have been made with your staff minister/counselor or lay counselor for more than four sessions. A typical session is 55 minutes, which consists of up to 45 minutes in session and 10 minutes of paperwork completion. If the issues presented indicate a need for intensive clinical counseling or psychotherapy, then in accordance with church policy, appropriate referrals will be made to Christian mental health professionals.
Referrals: When issues arise beyond staff scope of expertise, referral is suggested. In suggesting referral to outside agencies, Faith Chapel Christian Center Counseling Ministry does not provide endorsement or guaranteed results in overcoming issues. The counselee takes full responsibility for seeking out the proper treatment. Therefore, it is incumbent upon the counselee to seek out the desired “fit” regarding Professional Christian Counsel. In seeking that counsel, the counselee should ask certain questions.
Third Party Involvement: The Christian Counseling Department is a ministry of Faith Chapel Christian Center and is not a community mental health clinic. It does not operate under guidelines that may be associated with other community counseling organizations. All lay counselors, staff counselors and ministers, are employees and/or volunteers of the church and should be expected to conform to the beliefs, goals and guidelines established by the leadership of the same. To insure we remaintrue to the spiritual foundation and biblical principles of a Christ-centered ministry we reservethe right to decline to participate in any form of insurance filing for the purpose ofreimbursement. We will not participate in compliance reporting of workers’ compensation issues. The staff will not participate in legal disputes of any nature nor will they file any type of paperwork with the court system. ______Counselee’s initials
The information contained herein and the following data sheets are true and complete to the best of my knowledge. I have carefully read, understand, and agree to all of the above terms and conditions.
______
Counselee signaturedate
All applicants must complete the questions listed below. ALL INFORMATION GIVEN IS CONFIDENTIAL.
General Information (For Assessment Purposes)
Date ______
Name ______
Address ______
Phones/Home______Cell (optional) ______
Email ______Preferred Contact Method______
Sex: M____F____Date of Birth ______/______/______Age______
Presently Employed? ___Yes ___No How Long? _____ Highest Educational Level Attained______
Marital Status: _____ single_____engaged______married_____widowed______divorced
Name of Spouse (if applicable) ______Age of Spouse______Yrs. married _____
Christian Experience
Are you a member of FCCC? Yes_____No____
Are you in New Members’ Class? Yes_____No_____
How long have you been a member of FCCC? ______
Do you currently work in a ministry? If yes, please list_____
When do you receive Jesus Christ as your personal Lord and Savior? ______
Describe your salvation experience.______
When did you get filled with the Holy Spirit? ______. Describe the experience. ______Have you been water baptized since receiving Jesus as Lord and Savior? ______If yes, where______Year? ______Do you tithe on a consistent basis to FCCC? ______
How often do you attend Sunday Services? ______
Where do you attend Weekly Bible Study? ______
How often do you pray? ______
How often do you spend time reading the Bible? ______
Describe your quiet time. (Praying-English/spirit, confessions, bible study, worship) ______
Please answer all questions below.
Please indicate if you are now experiencing or have experienced any of the following:
____Emotional Outbursts ____Grief & Loss____Anger Issues
____Physical Abuse____Emotional Abuse ____Sexual Abuse
____Low self-esteem____Depression ____Anorexia
____Anxiety/Worry ____Substance Abuse
____Parenting Issues____Relationship Issues ____Spiritual Issues
Have you (or your family members) ever been in counseling? _____Yes_____No
If yes, with whom? ______When?______
Are you under a Physician’s care? _____Yes _____No Are you taking medication? _____Yes _____No
Please state the problem you are experiencing:
______
______
How long have you had this issue? ______
What have you done concerning this issue thus far? ______
What goals do you wish to accomplish during the sessions?
______
Counselee’s Statement of Agreement
I understand that I may be asked to do certain “homework exercises” such as reading, listening to CD’s, written assignments, practical exercises in communication, changing behaviors, and otherwise acting in my own best interest. I understand that I am entirely responsible for my own actions and I will always make my own final decisions regarding counseling.
I further understand that much of the work done will be to resolve issues and will depend on my honesty, and willingness to do the things I need to do to move forward even if it is painful and difficult.
I understand that whatever I say in a session is strictly confidential and will not be released to anyone without my consent unless I am violating codes of abuse, harm to myself or others.
The information contained in this form is correct to the best of my knowledge.
Counselee’s signature ______Date______
Parent’s signature ( if counselee is under the age of consent)
Date