Biblical Counseling Intake Form - Morning Star Community Church

Birthdate

If a minor, name of parents/guardian:

Requesting What Type of Counseling *

Individual

Pre-Marital

Marriage

Other

Method of Counseling *

Remote, video conferencing

In Person

Either

Gender

Phone number

Email

Address

Occupation

Employer

Referred By

How did you hear about us?

Emergency Contact Information

Name

Relationship

Phone Number

Email

Marriage & Family Information

For marriage counseling, we ask both spouses fill out the form separately.

Are you:

Single

Married

Separated

Divorced

Children: List name, age and gender of each child

Spiritual/Religious Information

Church Name:

How many times do you attend each month?

Please list ministry involvement:

Have you received Jesus as your personal Savior?

How would you define the gospel and what it means to be a Christian?

Have you been baptized?

Health Information

Are you currently taking prescription medication? If yes, please list.

If you are not currently taking prescriptions, have you ever been prescribed medication to treat a mental health issue? If yes, please list.

How would you describe your overall general physical health?

How often do you exercise?

How is your sleep?

Do you have any mental health related concerns (anxiety, depression, OCD, bi-polar, etc.)?

Do you struggle with suicidal thoughts?

Presenting Issues

Describe the current struggle for which you are seeking counseling.

What have you done about it (most effective and least effective)?

Please describe any family history that might be pertinent to your reason for seeking counseling.

Any further information that we should know? (relationship in family of origin, significant losses or events, etc.)

Special requests or accommodations:

Counseling Office Hours

We look forward to helping you. Due to the nature of our ministry and that it is funded with support of generous donations from our community, we do have limited hours. If this is an emergency, please call 911, or the Salem Psychiatric Crisis Center at (503) 585-4949. Once your intake form is received, you will be contacted within three business days to schedule an initial intake appointment.

Our Counseling office hours are Monday-Thursday, 9-5 p.m. During this time, we can be reached at (503) 581-2477. Counseling appointments are offered at various times depending on availability. We are unable to provide childcare for appointments and children are not allowed to wait in our waiting area. Thank you for your understanding.

Please list a few times you are available for an appointment. Limited availability may result in longer wait times.

(Day & hours)

Anything else you’d like to let us know about your availability?

Philosophy of Care

We are committed to providing a balanced and biblical approach to counseling. By biblical counseling we mean that your counselor is a Christian with special training and experience in applying the truth of the Bible to life. We believe that the Bible speaks to all of life and to all its problems, but it takes careful thought and prayerful wisdom to know how to make those connections. We don’t believe that the Bible is simply a how-to book for happiness.

We are confident that through the Scriptures and the power of His Spirit, God has given us all the instruction necessary for life and godliness (2 Peter 1:3-4). It is our joy to help real people with real problems using the Bible. Your counseling will be biblical, pastoral counseling in which the Scriptures are held as the final authority in all matters. If you are not sure that you will be interested in biblical counseling, you will have the option of attending one or two sessions to discover how biblical counseling may help you.

Most importantly, we believe that the Bible ultimately points us to a Person – the Lord Jesus Christ. We believe that real change comes when people learn to see themselves and their problems in the context of a loving, vital relationship with Christ. This does not mean that you must be a Christian to profit from our counseling, although we believe that deep and lasting change is brought about only by God Himself. Because of this, we do not use the Bible in either a superficial or heavy-handed way.

When necessary, we will work with your physician or other professionals to ensure you receive the appropriate medical care in conjunction with the counseling services you receive.

The Biblical Counseling Ministry Team:

Morning Star Community Church Biblical Counseling Ministry utilizes the help of both trained lay volunteers and pastors. Our counselors do not know everything about biblical teaching and its application to life; nevertheless, they do know much and will do their utmost to help you. Counselors will honestly tell you if they require additional assistance from another member of the Biblical Counseling Ministry. Please understand that biblical counseling consists of Christians providing scriptural advice and practical application. Yet the counselee is held fully responsible for how he/she implements that advice (James 1:23-25). In addition, our counselors are neither psychologists, nor professional counselors. The counseling team consists of pastors, lay counselors, and trainees under the direction of the church elders who provide guidance and oversight. The staff of Morning Star Community Church Biblical Counseling Ministry will supervise the trainees and lay volunteers. A biblical counselor trainee may be present in any counseling session for training and observation.

Your Rights as a Counselee:

As a counselee, you have the right to discuss outcomes and challenges regarding the counseling and receive an estimate of the predicted length, goals, and outcome of the counseling, as well as alternative options to that counseling. You have the right to ask about and/or refuse any techniques used. You are encouraged to report to an elder/pastor or counseling director if you have any grievances regarding the counseling. You may terminate counseling at any time, but we encourage you to consult with your counselor as to the best way to do so.

Not Professional Advice:

If you have significant legal, financial, medical, or other technical questions, we may help you seek advice from an independent professional in that field.

Referral Process:

We believe in biblical counseling and the future support of the Body of Christ once counseling is completed. However, in the case that progress is not being made, a conflict of interest, or for medical concerns, we do make referrals. With your permission, we will work with your family physician and insurance to help seek medical or professional care if needed.

Homework:

Homework is sometimes given between sessions. This can range from reading information to taking a practical step in your counseling process.

Signature:

Date:

Confidentiality Clause

Confidentiality is an important aspect of the counseling process. We carefully guard the information you entrust to us to the fullest extent possible. As a church-based counseling ministry, we do not offer absolute confidentiality. There are times when it may be necessary for us to share specific information with others. Examples include but are not limited to matters of church discipline (cf. Matt 18:15 ff.), divorce and separation which may include notifying the pastor/elder of counselee’s attending church, criminal activities, and potential harm to self or others. Additionally, when a counselor is uncertain how to address a particular situation, the counselor may consult with another member of the Biblical Counseling Ministry team and Pastor at Morning Star Community Church for the purpose of providing the highest level of care within the ministries of the church. To best care for you, we will work together as a ministry team while keeping the circle of confidentiality as tight as possible.

There are times when counseling information may be shared outside the church context. Those exceptions would include, but are not limited to the following:

- Known or suspected abuse of any kind
- The intent to take criminal actions or violence against another person
- Credible suicidal thoughts or intentions

If you are suicidal during the course of your counseling with your counselor, it is crucial that you talk with your counselor about these matters. By signing below, you agree to share any suicidal thoughts or intentions with your counselor at any time they arise, and by phone if they occur in between sessions, and that you will seek medical care if you become suicidal in the course of your counseling.

In the case of marriage or family counseling, there is limited confidentiality, meaning the confidentiality belongs to the couple and not the individual.

Confidentiality for counseling at Morning Star Community Church is defined by pastor-parishioner privilege because we are a local church and our counselors operate as agents of the church (pastors/ministers), not agents of the state (licensed counselors). This means counseling conversations are inadmissible in the court of law. All counseling forms and notes taken by the counselor are the property of Morning Star Community Church Biblical Counseling Ministry. They are protected as confidential and may not be used in court proceedings or in any other way that is not authorized by the Biblical Counseling Ministry Team. If your counseling needs require professional representations in a court setting by a counselor, Morning Star Community Church Biblical Counseling will likely not be the best fit for your needs.

Signature:

Date:

Waiver of Liability

In seeking counseling from Morning Star Community Church Biblical Counseling Ministry, please acknowledge your understanding of the following conditions and further release Morning Star Community Church, its elders, staff, counselors, employees, and all ministry team leadership from any legal liability, claim, or litigation arising from your participation in this voluntary program:

1. Counseling will be provided by pastors or church-trained lay leaders. The counseling staff is not a licensed counseling service through the state of Oregon.

2. All counseling is provided in accordance with the biblical principles adhered to by Morning Star Community Church and is not necessarily provided in adherence to any local or national psychological or psychiatric associations.

3. No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the above-mentioned counselors, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions.

4. In consideration for receiving any form of counseling from Morning Star Community Church, the person receiving the counseling agrees to release and waive any and all claims of any kind against the ministry, the staff, the pastoral/lay encouragers or any participating church, which may arise from, result out of, or be related to conduct or advice given.

Signature:

Date:

Morning Star Community Church Biblical Counseling Policies

I understand that Morning Star Community Church may terminate services for noncompliance with the agenda of care and/or agreed upon administrative issues, failure to keep or cancel appointments, criminal misconduct, violence, or other similar issues.

Having clarified the principles and policies of our counseling ministry, we joyfully anticipate the opportunity to walk with you as Christ enables you to grow in spiritual maturity and usefulness to His body. If you have any questions about these guidelines, please speak with your counselor or call the church office (503) 581-2477.

Signature:

Date: