lay counseling intake form

All information will be treated with the utmost confidentiality.

Preferred Contact #:(Required)

Is this a mobile or landline?(Required)

Mobile

Landline

Mark all times you are available to meet with one of our counselors at First Baptist Church of Powell’s counseling offices:(Required)

Counseling Model

Please read the following before becoming a participant in counseling. Our counseling approach consists of a Spiritual/Educational perspective. It is geared to believers who have, by faith, trusted in Christ’s blood atonement for freedom from their sin and guilt.

Our belief is that underlying every problem is a spiritual issue. Therefore, the focus of our counseling is not on behavior change but on the Holy Spirit’s transformation of the individual.

When an individual participates in this model of counseling, it is expected that his or her desire is to mature in Christ and to know Him more intimately. Our policy further maintains that the participant must request counseling themselves and must be committed to pursuing counseling without outside influences upon their doing so.

A specific process is involved in this model of counseling for individuals and couples. It begins with clarifying the problem, establishing goals for counseling, getting a personal history as well as a history of the problem. This information is utilized to identify false beliefs and defeating behaviors that have been brought into adult relationships. These patterns will be charted out for each individual.

After this, each participant will be introduced to the Spiritual solution. There will be assignments to assist the counselee’s learning to relinquish dependency on his/her old ways in order to allow Christ to be lived out through him/her in relationships. This involves addressing issues such as anger, forgiveness, purposes of adversity, personal “brokenness” and surrender. Then, there is the process of discipling the participant in abiding in Christ, and renewing the mind to Truth as he/she faces daily circumstances.

Homework will be an integral part of the change process. Counseling will not be effective if the homework is not accomplished. Expect to come for counseling appointments only after all of the homework is done. Reading books for discussion as well as listening and viewing assignments are required as large parts of the homework.

Those who decide to come for marriage counseling must understand that one spouse is not to participate as a result of an ultimatum given by the other spouse. Both must agree to our stated perspective. It must be understood that, in marriage counseling, the solution will not include giving hope that the other spouse will change.

We do not accept court-mandated counseling clients. Regarding children/family counseling, we will not participate in child custody issues or any issues that involve us as participants in court proceedings or may result in court proceedings in the future. In these circumstances, referrals may be given.

Those who participate in counseling are required to:

1. Attend all sessions.

2. Be on time for every counseling appointment.

3. Have a heart for knowing Christ and for growing to maturity in Him, because our counseling model is based on this - and does not involve primarily teaching behavior modification and “dos” and “don’ts”. The spiritual focus is on the change of the person and being transformed by the renewing of the mind.

4. Understand that behavioral changes such as communication skills, problem-solving techniques, and anger management strategies will not be considered the solutions to the participant’s problems. Personal transformation in Christ is the only answer and hope for relational as well as personal issues.

5. Not expect personal healing and peace to depend on the circumstances, spouse or another person changing. Fulfillment and freedom from emotional pain is to be found only in understanding God’s grace, identity in Christ, and pursing an intimate relationship with Him.

6. Understand that participants with a substance abuse addiction are to be referred to a treatment program before counseling can begin (or continue). Once the participant has completed the treatment program, the counselor may proceed with counseling assuming that the participant is faithful to his or her aftercare program.

7. Complete weekly homework. This may involve an hour or more per week. Homework may include reading, writing, audio and/or viewing assignments, doing relational exercises, or all of the above.

8. Come to counseling sessions only when assigned homework has been completed. This is because in the counseling process each session builds upon the previous session and upon the homework.

9. Agree to refrain from discussing with anyone else, outside of counseling sessions, problematic relationships and what takes place in counseling.

10. Participate in counseling because you have a desire for personal change through knowing Christ, not as a means of satisfying someone else’s expectations.

11. Realize that the purpose of counseling will not be to change another person with whom there is a relationship.

12. Adhere to our policy that electronic devices such as cell phones, tablets, and laptops must be turned off during counseling sessions. In addition, the use of these devices is not permitted in the Counseling Ministry Reception Area. To respect the privacy and confidentiality of others, please use the areas outside of the building for these purposes.

13. Understand that becoming a participant in counseling may involve completing application materials that include the Beck Depression Inventory II (BDI II), the Holmes-Rahe Stress Test or the Taylor Johnson Temperament Analysis (TJTA).

By signing and dating below I acknowledge that I understand the conditions of participating in counseling, and I agree to the expectations listed above (note: when both spouses are seeking marriage counseling, then both must complete, sign and date their own individual Intake Form):

Counselee's Signature:(Required)

Date:(Required)

Financial Policy

MEMBERS - We welcome you to the Lay Counseling Ministry of the First Baptist Powell. This ministry is designed primarily to serve our members and is funded through the church budget.

RECOMMENDED RESOURCES - Books and other resources that are recommended by your counselor may be available for purchase or from First Baptist Powell’s Counseling Library for borrowing.

TESTING & MATERIALS FEE - There may be a fee or fees associated with any testing and materials required by the counselor. These fees will be discussed with the counselee prior to charges being incurred, and should fees be assessed, counselee will be responsible for these costs.

Application For Adults

Today's Date:(Required)

Name:(Required)

First Last

Age:(Required)

Date of Birth:(Required)

Spouse's Name (If Married):

First Last

Spouse's Age:

Spouse's Date of Birth:

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Home):(Required)

Phone (Work):(Required)

Phone (Cell):(Required)

Email:(Required)

Employer:(Required)

Job Title:(Required)

What sort of work are you doing now?(Required)

Does your present work satisfy you?(Required)

Yes

If no, please explain:(Required)

What kind of jobs have you held in the past?(Required)

Education (High School):(Required)

Education (College):(Required)

Religious Background:(Required)

Present Church Membership:(Required)

Please indicate ALL marital relationships (past and present), making note of wedding, separation, divorce, and death dates:(Required)

Names and ages of your children (designate any that are stepchildren):(Required)

Number of miscarriages (if any):

Number of abortions (if any):

Personal and Social History

Father's Name:(Required)

First Last

Age:(Required)

His Health?(Required)

His Occupation?(Required)

Deceased?(Required)

Yes

Date/Cause of Death?(Required)

Mother's Name:(Required)

First Last

Age:(Required)

Her Health?(Required)

Her Occupation?(Required)

Deceased?(Required)

Yes

Date/Cause of Death?(Required)

Are or were your parents separated or divorced?(Required)

Yes

If you were not raised by your parents, by whom were you raised and during what years:

Give a brief description of your Father’s personality and his attitude toward you (past & present):(Required)

Give a brief description of your Mother's personality and her attitude toward you (past & present):(Required)

Names and ages of your brothers and sisters (include yourself and any half-brothers and sisters):(Required)

Check any of the following that applied during your childhood/adolescence:(Required)

Other:(Required)

Please comment on any that applied:(Required)

In case of emergency, whom should we notify?

Name:(Required)

First Last

Relationship:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Please complete the following:

Have you reached the place in your spiritual life where you know for certain that if you were to die today that you would go to heaven?(Required)

Yes

Uncertain

If you checked yes, according to your beliefs, on what basis would God let you into His heaven?(Required)

Have you received counseling before?

Yes

If yes, at First Baptist Powell?(Required)

Yes

Date(s) of previous counseling:(Required)

Name(s) of counselor(s):(Required)

Are you under the care of a physician?(Required)

Yes

If so, list name of physician:(Required)

Are you under the care of a psychiatrist?(Required)

Yes

If so, list name of psychiatrist:(Required)

List the name(s) of the medication(s) you are currently taking:(Required)

Have you ever been hospitalized for psychological/psychiatric problems?(Required)

Yes

If yes, when and where?(Required)

Has any relative of yours attempted or committed suicide?(Required)

Yes

Have you ever attempted suicide?(Required)

Yes

Check all of the emotional, physical, or mental disorders listed that apply to you (if any):

Check all of the emotional, physical, or mental disorders listed that apply to any member of your family (if any):

Please identify the family member(s) who suffer(s) from any disorders checked above:(Required)

What is the specific problem that has caused you to seek counseling?(Required)

What have you done about this problem up until this point?(Required)

On the scale below, please estimate the severity of your problem(s):(Required)

When did your problem(s) begin?(Required)

What seems to worsen your problem(s)?(Required)

What have you tried that has been helpful?(Required)

As you see yourself, how satisfied are you with your life as a whole these days (with 1 being not at all satisfied and 7 being very satisfied)?(Required)

How would you rate your overall level of tension during the past month (with 1 being relaxed and 7 being tense)?(Required)

Is there any other information we should know?

Expectations Regarding Counseling

In a few words, what do you expect your counselor to do to help you with your problem(s)?(Required)

What personal qualities do you think the ideal counselor should possess?(Required)

Are you open to God's solution?(Required)

Yes

Are you open to God's solution?

Information and Confidentiality Statement

METHODS - Information about our methods and techniques of counseling is available to those who wish to have it. Our counseling is biblical, Christian counseling based on the truths of Scripture. Counselees are encouraged to raise any questions they may have concerning our counseling model.

LAY COUNSELING CREDENTIALS - The Lay Counseling Ministry Staff counselors are not “professional” counselors. Our counselors’ credentials do include training in biblical counseling. The staff may also possess professional and/or specialty licensure and/or membership in a professional Christian counseling association. The Lay Counselors are trained in a Bible-based model of counseling and in listening and helping skills from Christian professionals trained in individual and marital counseling. The Lay Counselors are not professionals in psychological counseling, psychiatric therapy, or marriage and family counseling or therapy, and are not licensed by the State of Tennessee as counselors, social workers, or therapists. They do receive continual training and are under the supervision of the Elders and Counseling Ministry Staff of First Baptist Church Powell.

MISSED APPOINTMENTS - If a participant is unable to keep an appointment, he or she must call the FBP Lay Counseling Ministry office at 865-740-6305 to cancel. For weekday appointments, notification of cancellation is expected 24-hours in advance. For Sunday appointments, please contact the office by the previous Thursday evening. Failure to do so may result in interruption and/or termination of counseling. We understand emergencies happen. Please keep us informed. We appreciate your cooperation in this matter. Time is a gift from God; may we all be good stewards. The Lay Counselors freely volunteer their time to this ministry.

CONFIDENTIALITY STATEMENT - The communications between you and your counselor will be considered confidential except where disclosure is required by law, i.e., where there is a threat of serious harm to self or others, as in the case of child abuse, suicide, threatened violence, or homicide. Because the Lay Counseling Ministry at First Baptist Church of Powell is also a training center, you may also be assigned a co-counselor who is also bound by the duty of confidentiality imposed upon all counselors in this Lay Counseling Ministry.

RESOURCE POLICY Books and other resources related to your counseling may be available for purchase from the FBP Lay Ministry Resource Library. Should you choose to borrow any resources; the following policy will be applied: As a condition of counseling, I agree to return or purchase all resources by the due date.

Counseling Agreement

By signing this document, I am, of my own free will, knowingly authorizing counselors of the Lay Counseling Ministry of First Baptist Powell to render counseling and/or referral services to me. Likewise, I have been informed of the nature and purposes of the Bible-based Lay Counseling Ministry services and that my consent may be revoked orally or in writing prior to, and/or during the counseling session. I understand that if I am assigned to a Lay Counselor and/or Co-Counselor trainee, they are not a professional counselor, social worker, or therapist. I have read and fully understand my rights as a client and that my counselor will disclose my communications to law enforcement officials as required by law. I further understand and hereby give my permission for my counselor to disclose his/her written and taped records of my counseling sessions with his/her ministry supervisor for the purpose of receiving supervision regarding my care and his/her training. If I am unable to keep an appointment, I agree to notify the Lay Counseling Ministry office at least twenty-four hours prior. I agree that, in order to avoid the delay or interruption of my counseling, I will return my borrowed counseling materials by the deadline, or I will pay for the counseling materials I borrow but do not return by the deadline. No guarantee or assurance of any kind has been made to me with respect to any of the results that may be obtained from these services.

Counselee's Signature:(Required)

Date:(Required)

CAPTCHA

Counseling Model

Financial Policy

Application For Adults

Personal and Social History

Expectations Regarding Counseling

Information and Confidentiality Statement

Counseling Agreement

Location

Service Times

QUESTIONS?