Step 1 of 2 50% Name(Required) First Last Date MM slash DD slash YYYY Gender Date of Birth Address Phone Email Occupation Employer With whom do you currently live? Alone Spouse Parent(s) Father Mother Boyfriend/Girlfriend Other Who referred you to OB Care? Preferred date/time for the counseling session: Do you consider yourself to be a religious person? Yes No If Yes or No Explain:Name and city of church you attend: Are you a member of that church? Yes No Number of years as a member: Have you received Jesus as your personal Savior? Yes No Not sure what you mean Have you been baptized? Yes No If yes, when were you baptized? If applicable, what is the religious background of your partner? Do you read the Bible? Yes No If yes, how often do you read the Bible? Please note any changes to your spiritual life recently: Counseling History - Have you ever had counseling before? Yes No Have you seen a psychiatrist before? Yes No Please provide a brief explanation of any major previous counseling experiences: Please include the following: your age at the time, duration of the counseling, name of the counselor/center, issue(s)/topic/diagnosis, & your evaluation of counseling received Current counseling needs - Please describe the current problem, as you understand it:(Required) What have you done about it so far (most effective and least effective)? Other than counseling, what help are you seeking? Please describe any family history which might be pertinent to the concerns that you bring to counseling (your relationship with your parents, their relationship with each other, significant losses or events): What are your expectations in seeking counseling here? What, if any, are your concerns about coming to counseling? What do you believe will have to change to see the progress you desire? Is there any other information we should know? Consent(Required) I agree to the Consent to Counseling PolicyOur Goal - Our goal in providing counseling is to help you meet the challenges of life in a way that will please God (1 Cor. 10:31) and bring you the greatest joy and satisfaction (John 15:11). Biblical Basis - We believe that the Bible provides thorough guidance and instruction for faith and life (2 Timothy 3:16-17; 2 Pet. 1:3-12). Therefore, our counseling is based upon Scriptural principles. Our counselors may not be licensed or trained as psychotherapists or mental health professionals, nor should they be expected to follow the methods of such specialists. All counseling will be conducted in accordance with the counselor’s understanding of the Scriptures. Not Professional Advice - If you have significant legal, financial, medical or other technical questions you should seek advice from an independent professional. Our counselors will cooperate with such advisors and help you to consider their counsel in light of Scriptural principles. Our counselors do not give professional advice. Termination – At any time during the counseling, for reason(s) sufficient to him or her, the counselor or counselee has the option of terminating the counseling. Confidentiality - Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. There are situations, however, in which the counselor may believe that it is wise or mandated (Biblically or legally) for them to share certain information with others. Some examples would be: 1. When a counselor is uncertain how to address a problem and needs to seek advice from another pastor or counselor. 2. When there is concern that someone may be harmed unless others intervene. 3. When abuse or another crime must be reported to the authorities. 4. When observers sit in on counseling sessions to assist the counselor or for training purposes (including audio & video recordings with explicit permission only). Please note that if the counselee is a member of another church, out of respect for that ministry, the counselor may suggest the counselee meet with the staff of the counselee’s church first. Please be assured that our counselors strongly prefer not to disclose your personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible. Our Fee – Part of the weekly homework assignments will usually require the purchase of materials that correspond to the counseling. Those materials are yours to keep once purchased. The actual counseling is performed free of charge as a ministry of Open Bible. If, out of gratitude, one wishes to express his thanks in a tangible way, donations can be made to Open Bible in support of the OB Care ministry. Please note that we do not require a specific time limit to be placed on any counseling session. That being said, out of respect for other people who may be seeking counsel the same day, the counselor reserves the right to end any counseling session where they deem appropriate and to suggest a follow-up session for continued discussion if need be. Your Rights as a Counselee: As a counselee you have the right to discuss possible outcomes and challenges regarding counseling and receive an estimate of the predicted length, goals, and outcome of counseling, as well as alternative options. You have the right to ask about and/or refuse any techniques used. You are encouraged to report to the pastor of Open Bible if you have any grievances regarding your counseling. You may conclude counseling at any time, but we encourage you to consult with your counselor as to the best way and time to do so. Resolution of Conflicts (Arbitration) - On rare occasions a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts will be resolved in a Biblically faithful manner, we require all of our counselees to agree that any dispute that arises with a counselor as a result of counseling will be settled by mediation and, if necessary, legally binding arbitration; judgment upon an arbitration award may be entered in any court having jurisdiction. It is expressly understood that by agreeing in advance to arbitrate that the counselee is giving up his right to a trial in the civil courts. Conclusion & Signature - Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Jesus and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His local church. If you have any questions about these guidelines or conditions, please speak with your counselor. Having read the foregoing information and conditions fully and completely, my signature below indicates that I understand all the material presented in this document, understand that it applies to any current as well as future counseling from OB Care, and fully agree to comply. *The Counseling Request Form is adapted from the Counseling Intake Forms from Faith Youngsville in NC © 2020 Thank you for taking the time to complete this form. The information you have provided will enable us to better serve you. *Only required if counselee is under 18 years of age *The Consent to Counseling Form is adapted from Consent to Discipleship Counseling © Stuart W. Scott, 2009 Name(Required) First Last Parent/Guardian Name First Last *Only required if counselee is under 18 years of age.Date MM slash DD slash YYYY By checking this box you are verifying your digital signature(Required) I agree to checking this box as my digital signatureThank you for taking the time to complete this form. The information you have provided will enable us to better serve you. Δ
