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Personal Data Inventory

For Assessment Purposes

All applicants must complete the questions listed below. All information given is confidential.

Name*
Date*
Address*
Gender*
Date of Birth*
Presently Employed?*
Relationship Status*
Name of Spouse
Please tell us if you are:*
Did someone refer you to counseling?*
Is there a specific counselor you'd prefer to meet with?*

Christian Experience

Are you a member of a church?*
Do you currently work in ministry?*

Health

Are you under a physician's care?*
Are you taking any medication?*
How would you rate your health?*
Do you have any problems with sleep?*
Do you have any chronic health issues?*
Have you ever used drugs for anything other than medical purposes?*
Do you drink alcohol?*
Have you ever been arrested? *

Counseling

Have you or a family member ever been in counseling?*
Have you ever attempted suicide? *
Please indicate if you are now experiencing (or have experienced) any of the following:*

Counselee's Statement of Agreement

I understand I may be asked to do certain "homework exercises" such as reading, listening to CD's, written assignments, practical exercises in communication, changing behaviors, and otherwise acting in my own best interest. I understand I am entirely responsible for my own actions, and I will always make my own final decisions regarding counseling. 

I further understand that much of the work done will be to resolve issues and will depend on my honesty and willingness to do the things I need to do to move forward even if it is painful and difficult. 

I understand whatever I say in a session will not be released to anyone without my consent, with the exception of consultation with a counseling supervisor or colleague, (as stated in the Counseling Agreement on the next page) or I am violating codes of abuse, or harm to myself or others.

The information contained in this form is correct to the best of my knowledge.

Counselee's Statement of Agreement*
Name*
Signature Date*
Parents Signature (if under the age of consent)*
Parent's Signature Date*

Counseling Agreement

Welcome to the Center for Biblical Counseling where we seek to offer biblically based counseling/guidance addressing the many common difficulties of life. Our team consists of staff counselors, volunteer lay counselors, and student interns who have been called into the helping ministry of biblical counseling and guidance.

QUALIFICATIONS OF COUNSELORS

Our staff and volunteer counselors have years of experience ministering to the personal needs of individuals. The staff counselors, biblical counseling interns, lay counselors and ministers do not possess professional licenses or certifications issued by the State of New York. Our counseling is solely based on the principles of Scripture and does not use the teaching or methods of secular psychology or psychotherapy. None of the staff- paid or volunteers - of the Center for Biblical Counseling will render any legal or medical opinions or advice.

All counseling will be done in accordance with the counselor's understanding of the Scriptures. While our counselors do not pretend to know all there is to know about biblical teaching and its application to life, they, nevertheless, will do their best to help you. Counselors will honestly tell you if they are uncertain on how to continue and will seek further help if necessary.

OUR APPROACH

Counseling received at the WOL Center for Biblical Counseling is religious in nature. We believe the Bible provides sufficient guidance for all matters of life and faith (c.f., 2 Timothy 3:16-17 and 2 Peter 1:3-4). The Center for Biblical Counseling employs a method of biblical counseling and guidance utilizing spiritual/biblical principles and their practical application to each individual. In this kind of discipleship process, the Holy Spirit, not the counselor, is the agent of individual change while the counselee is fully responsible for how he/she implements that advice.

SESSION LENGTH

A typical session is one hour. The first session may last 90 minutes. Counselors typically take notes, and we ask that the counselees come prepared to take notes as well.

FEES

We want to bless our Bible Institute community by providing these counseling services. There is no cost for the biblical counseling services. However, some resources like books and other literature are often used during the counseling process and it is the responsibility of the counselee to purchase such resources.

TRAINING CENTER

The WOL Center for Biblical Counseling is also a training center for future biblical counselors. Therefore, in order to facilitate both training and counseling, observers may sit in on counseling sessions.

CONFIDENTIALITY

We view confidentiality as a vital element in the counseling process. It is understood (and agreed) that all statements, whether written or verbal, are of a confidential nature and ethically cannot be disclosed without written consent. However, absolute confidentiality cannot always be adhered to as in the following exceptions where confidentiality may be waived:

1. We reserve the right to report child abuse or suspicion of child abuse of any type to the proper authorities and/or the right to cause a report of child abuse to occur.

2. We reserve the right to disclose to the appropriate person, agency or civil authorities any harm that a person may attempt or desire to do to oneself or to others.

3. To ensure the highest quality discipleship process, as a rule your counselor/lay counselor will consult with a supervisor or colleague regarding your sessions(s).

All observers, trainees, and counselors agree to be bound by this agreement. 

LATE AND RESCHEDULING POLICIES

It is to the counselee's advantage to be on time in order to receive the full benefit of the scheduled appointment. In the event you need to reschedule or cancel an appointment, we ask that you notify your counselor or the CBC at least 24 hours in advance. This allows us to reschedule others who are waiting. Counselees more than 15 minutes late to their scheduled appointment will be asked to reschedule.

RESOLUTION OF DISAGREEMENTS

On rare occasions, a disagreement may arise between the person receiving counseling and the lay counselor, student intern, staff counselor, and/or minister regarding the counseling session. If it is unable to be resolved, one should bring this dispute to the attention of the Director of Biblical Counseling. The Bible directs us to make every effort to live in peace and harmony and to resolve disputes with each other (Romans 12:18; 1 Corinthians 6:1-8).

COUNSELING MINORS

We believe the primary responsibility for discipling children and teenagers rests with their parents. Accordingly, the counselor may share information from the counseling sessions with either or both of the custodial parents when appropriate to do so. When requesting counseling for a teen, a consent to counsel must be signed by the teen and a custodial parent.

WAIVER OF LIABILITY

In consideration for receiving biblical counseling and guidance from the Center for Biblical Counseling, the person receiving counseling agrees to release and waive any and all claims of any kind against the lay counselor, staff counselor, student intern, minister or the church, which may arise from, result out of, or be related to their counsel or conduct.

At any time during the counseling, for reasons sufficient to the counselor as well as the counselee, each shall have the option of terminating the counseling.

REFERRALS

In the process of biblical counseling there are often times when there is a need for significant advice with regards to legal, medical, financial or other technical areas. In those cases, you will be encouraged to seek independent professional counsel. In suggesting a referral to outside agencies, the Center for Biblical Counseling does not provide endorsement or guaranteed results in outcomes. The counselee takes full responsibility for seeking out the proper counsel.

THIRD PARTY INVOLVEMENT

The Center for Biblical Counseling is a ministry of Word of Life Bible Institute and is not a community mental health clinic. It does not operate under guidelines that may be associated with other community counseling organizations. All lay counselors, staff counselors, interns and ministers are employees and/or volunteers of Word of Life and should be expected to conform to the beliefs, goals and guidelines established by the leadership of the same. To ensure we remain true to the spiritual foundation and biblical principles of a Christ-centered ministry, we reserve the right to decline to participate in any form of insurance filing for the purpose of reimbursement. We will not participate in compliance reporting of workers' compensation issues. The staff will not participate in legal disputes of any nature, nor will they file any type of paperwork with the court system.

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