Counseling Intake Form

We offer counseling appointments in our offices; please check the location at which would you would like to receive counseling:*

Consents and Agreement

I/we desire to receive counseling and ministry from Faith Biblical Counseling Ministries, Lafayette, Indiana (“FBCM”). I/we make the following acknowledgements and agreements and give the following consents:

  1. The counseling will be by a counselor who is trained in biblical counseling who may or may not have other certifications or degrees.
  2. A basic principle of biblical counseling is that the Bible is sufficient to understand how to live a God-pleasing life.
  3. The counseling I/we will receive will be based upon scriptural principles rather than principles of psychology or psychiatry.
  4. The counseling I/we will receive will be based on the conclusions that the Bible is inerrant and authoritative, and contains God’s answers to the issues of life, conduct and relationships.
  5. The counseling I/we will receive will reflect the counselor’s understanding of the Bible and how the principles of scripture apply to the problems, questions or issues involved.
  6. Because FBCM is also a training ministry, trainees (i.e. those being trained in biblical counseling) may be present in the counseling sessions and they will abide by the confidentiality statement articulated in #9 below.
  7. FBCM wants to be a blessing to the community by providing facilities and counselors who volunteer their time and services. While the counseling is free there is a $25.00 cancellation fee payable in cash at the first counseling session. If an appointment is cancelled less than 72 hours before the scheduled time for counseling, the counselee will forfeit the cancellation fee and he or she must submit another $25.00 in cash before continuing in counseling. If all sessions are attended or timely cancelled, the cancellation fee will be returned at the final counseling session.
  8. If a dispute arises concerning the counseling of FBCM, or between a counselee and the counselor involved, or with Faith Church (“the dispute”), there shall be no lawsuit initiated and the claim cannot be filed in any state or federal civil court. Instead, the dispute must be resolved as follows:

    The parties hereby exercise their election, as provided in Indiana’s Uniform Arbitration Act (I.C. §34-57-2-1 et seq.) to submit any disputes or claims to Christian resolution. The parties understand that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian church (see Matthew 18:15-20; 1 Corinthians 6:1-8). If all parties agree, the dispute can be submitted to the binding arbitration decision of agreed-upon local pastors and/or church leaders who would decide and judge between the parties, applying the principles of First Corinthians Chapter 6 and Matthew Chapter 18, as well as any other applicable scriptures. The parties understand that Christian dispute resolution methods shall be the sole remedy for any such dispute or claim. The parties further agree that if they fail to agree to submit the dispute or claim to local pastors and/or church leaders, then they hereby agree that any such claim or dispute arising from or related to the counseling at and by FBCM, or with a counselor or with Faith Church shall be settled by legally binding Christian arbitration, in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker® Ministries (1537 Avenue D, Suite 352, Billings, MT), including its Rules as found at www.HisPeace.org.
  9. Counseling at FBCM, including statements made during counseling, shall remain confidential, with the following qualifications and exceptions:
    1. Counselors shall be free to discuss counseling sessions and cases with other FBCM counselors and the pastors of the Faith Church, Lafayette, Indiana in order to gain the benefit of additional insight and input;
    2. Counselors and pastors shall be entitled to seek a confidential legal opinion or advice from an attorney when it is deemed appropriate and helpful;
    3. If any FBCM policy concerning the reporting of child abuse or child neglect, or the reporting of elder abuse or elder neglect, mandates a report to Child Protective Services or other authorities in compliance with the laws of the State of Indiana, then such report will be made;
    4. If a suicide risk is indicated, the counselors or pastors may seek necessary help and make whatever reports or disclosures as they deem to be proper and necessary;
    5. If a counselee indicates an intention to commit a crime, such intention may be reported and disclosed to the proper authorities;
    6. If the counselee is a member of a local church other than Faith Church, and if the pastors of Faith Church deem it necessary or helpful to communicate information or facts to the pastor of the counselee’s local church, they may do so.

I/WE HAVE READ AND UNDERSTAND THE ABOVE PROVISIONS, AND I/WE UNDERSTAND THEM AND I/WE HEREBY ACKNOWLEDGE AND AGREE TO ALL OF THE ABOVE TERMS, INCLUDING, BUT NOT LIMITED TO, THE CANCELLATION POLICY, WAIVER OF SEEKING REDRESS (LAWSUIT) IN THE CIVIL COURT SYSTEMS, AND AGREEING THAT ANY AND ALL DISPUTES BE RESOLVED THROUGH CHRISTIAN RESOLUTION AS DETAILED ABOVE.

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Personal Data Inventory: Identification Data

Name*
Address*
Put "N/A" if not applicable.
Sex*
Date of Birth*
Marital Status*
How many children do you have?*
Education (Highest Years Completed)*
Education (Highest Years Completed)
  1 2 3 4 5 6 7
Grade School
High School Education
  0 9 10 11 12
High School
College/Grad Education
  0 1 2 3 4 5 6+
College/Grad
Put "N/A" if not applicable.
Put "N/A" if not applicable.
Referred here by*
How did you find out about us?*

Personal Data Inventory: Health Information

Rate your current physical health*
Recent weight changes*
Put "N/A" if not applicable.
Date of last medical examination*
Have you ever had a severe emotional upset? *
Have you ever had a problem with alcohol or drug abuse (prescription or non prescription)? *
Have you ever been physically abused as a child or as an adult? *
Have you ever been sexually molested, either as a child or as an adult? *
Have you ever been or are currently a resident at Vision of Hope or Restoration Ministries?*
Have you seen a psychologist, psychiatrist or/and counselor? *
Are you willing to sign a release of information form so that your counselor may write for helpful social, psychiatric, or medical report? *
Have you ever been arrested? *
Have you ever used drugs for other than medical purposes? *
Are you presently taking any medication? *
Prescribed or Over-the-Counter?*

Personal Data Inventory: Religious Background

Put "N/A" if not applicable.
Are you a member of a church? *
What is the name of the church of which you're a member?*
Have you contacted your pastor requesting permission to receive counseling at Faith Biblical Counseling Ministries?*
Your Pastor is Welcome to attend your counseling sessions with you.
Church attendance per month*
Put "N/A" if not applicable.
Baptized?*
Are you saved? *

Personal Data Inventory: Marriage Information

Name of spouse*
Spouse's Address*
Is your spouse willing to come in for counseling? *
Have you ever been separated? *
e.g. From 9/9/90 to 10/10/91
Has either of you ever filed for divorce? *
Is this your first marriage*

Personal Data Inventory: Children

Child 1 Info

Child 1's Name*
Child 1's Sex*
Is Child 1 from a previous relationship?*
Is Child 1 still living in your home? *

Child 2 Info

Child 2's Name*
Child 2's Sex*
Is Child 2 from a previous relationship?*
Is Child 2 still living in your home? *

Child 3 Info

Child 3's Name*
Child 3's Sex*
Is Child 3 from a previous relationship?*
Is Child 3 still living in your home? *

Child 4 Info

Child 4's Name*
Child 4's Sex*
Is Child 4 from a previous relationship?*
Is Child 4 still living in your home? *

Child 5 Info

Child 5's Name*
Child 5's Sex*
Is Child 5 from a previous relationship?*
Is Child 5 still living in your home? *

Child 6 Info

Child 6's Name*
Child 6's Sex*
Is Child 6 from a previous relationship?*
Is Child 6 still living in your home? *

Child 7 Info

Child 7's Name*
Child 7's Sex*
Is Child 7 from a previous relationship?*
Is Child 7 still living in your home? *

Basic Information Sheet

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