Name
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First Name
Last Name
Email
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Date
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Today's Date
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DD
YYYY
What is your age?
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What is your primary phone number?
Checkbox
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Can we leave a message on the above phone number?
How many hours a week do you work?
With whom do you currently live?
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Spouse's name
What is your spouse's age?
Have you ever been seperated?
How many years have you been married?
How long did you date or were you engaged before you were married?
How many previous marriages and give any information about them that would be helpful for us to know.
Do you attend church? If so, what is the name of your church?
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Number of years at this church?
How many times a month do you attend church?
If you attended church as a child, please tell us for how long and what denomination.
Was your church experience as a child a good one? Please tell us why or why not.
How often does your spouse attend church?
Do you and your spouse openly discuss and encourage one another in your faith?
Do you pray to God? If so, how often?
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If yes, what do you pray about?
Have you received Jesus Christ personally as your Lord and Savior?
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How would you define the Gospel of Jesus Christ and what it means to be a Christian?
Do you read the Bible and if so, how often?
Have you ever had counseling before?
If yes, please explain when and what you saw a counselor for. Also, what was the outcome?
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Have you ever seen a psychiatrist before?
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If yes, please explain when and what you saw a psychiatrist for. Also, what was the outcome?
Please check the boxes that best describe you now.
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Please list current illnesses, injuries, or disabilities.
If you are presently taking medication, please list along with the current dosages, frequency, and side effects that you are experiencing.
Have you used drugs for non-medical purposes? If so, what, why, and when?
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Do you drink alcoholic beverages? If so, how often?
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Describe your eating habits and any recent changes in appetite.
Describe your current exercise routine.
Have you recently gained or lost weight? If so, please explain.
How many non-working hours do you spend watching television? (Including Netflix or other online services)
How many non-working hours do you spend on the computer/phone?
How many non-working hours do you spend on hobbies?
Please check any of the physiological symptoms that apply to you.
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Please check any of the following struggles you and/or your family are experiencing at this time.
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Please describe the current problem/trial/struggle that you are seeking counseling for as you best understand it.
What have you done to address this situation thus far, if anything?
Other than counseling, what help are you seeking?
What are your expectations in 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?
Do you have a preference as to which counselor you see?
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Megan Canedy
Donna Fornwalt
First available
APPOINTMENT CANCELLATION POLICY: We want to be a good steward of the time and resources of the counseling ministry. Therefore, cancellation is expected 24 hours in advance. If you are unable to keep a scheduled counseling appointment, you should call or text your counselor to cancel. We understand emergencies happen, so please keep us informed. If you do not show up for an appointment without 24 hour's notice there will be a fee of $10.00. Guiding Light Biblical Counseling may terminate services for non-compliance with the agenda of care and/or agreed upon administrative issues, failure to keep or cancel appointments, failure to make payments, criminal misconduct, violence, or similar issues.
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Confidentiality Policy: 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. Matthew 18:15 ff.), 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 GLBC counselor for the purpose of providing the highest level of care. 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 critical that you talk with your counselor about these matters. By agreeing below, you consent to share any suicidal thoughts or intentions with your counselor any time they arise and 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 confidentiality belongs to the couple and not the individual. Confidentiality for counseling through Guiding Light Biblical Counseling is defined by pastor-parishioner privilege because we are a local church and our counselors operate as agents of the church, not agents of the state (licensed counselors). This means counseling conversations are inadmissible in the court of law in the same way as conversations with a priest in a confessional booth. All counseling forms and notes taken by the counselor are the property of Guiding Light Biblical Counseling. They are protected as confidential and may not be used in court proceedings or any other way that is not authorized by the Counseling Ministry team. If your counseling needs require professional representation in a court setting by a counselor, Guiding Light Biblical Counseling will likely not be the best fit for your needs. * Please choose the circle if you understand and agree with the above policies.
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WAIVER OF LIABILITY: In seeking counseling from Guiding Light Biblical Counseling, please acknowledge your understanding of the following conditions and further release Lighthouse Baptist Church, the deacons, 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 ACBC certified counselors. The counseling staff is not a licensed counseling service through the state of Delaware; 2. All counseling is provided in accordance with the biblical principals adhered to by Lighthouse Baptist Church and is not necessarily provided in adherence to any local or national psychological or psychiatric association; 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. It is understood by the participant counselee(s) that all complaints and grievances will be heard by the pastors and or the deacons of Lighthouse Baptist Church. If the goal of reconciliation cannot be achieved between aforementioned parties, then the participant counselee(s) may elect to involve Peacemaker Ministries, Inc. at their expense, for the purpose of mediation or arbitration. * Please choose the circle if you understand and agree with the above policies and wavier of liability.
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If you have read the policies in this document and if you agree with and understand each of these policies, and you are enrolling yourself into counseling of your own will, please type your own name below, this has the same effect as manually signing a paper original agreement.
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