Counseling Intake Form

Name

This address will receive a confirmation email

Phone

Address

Counseling Consent

I/We desire to receive counseling from CrossPoint Fellowship Biblical Counseling and therefore make the following acknowledgements and agreements and give the following consents:
-The counseling will be by a counselor who is trained in biblical counseling who may or may not have other certification or degrees.
-A basic principle of biblical counseling is that the Bible is sufficient to understand how to live a God-pleasing life.
-The counseling I/we will receive will be based upon Scriptural principles rather than principles of psychology or psychiatry.
-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.
-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.
-CrossPoint Fellowship Church not only does counseling but also trains biblical counselors; this means that the counselor may have one to two people observing him/her in each counseling session.
-Absolute confidentiality is not Scriptural. Counseling at CrossPoint Fellowship Church, including statements made during counseling, shall remain confidential, with the following exceptions;
-Counselors shall be free to discuss counseling sessions and cases with other CrossPoint counselors and the pastors of CrossPoint Fellowship Church, in order to gain the benefit of additional insight and input;
-Counselors and pastors shall be entitled to seek a confidential legal opinion or advice from an attorney when it is deemed appropriate and helpful;
-If any CrossPoint Fellowship Church 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;
-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;
-If a counselee indicates an intention to commit a crime, such intention may be reported and disclosed to the proper authorities;
-If the counselee is a member of a local church other than CrossPoint and if the pastors of CrossPoint deem it necessary or helpful to communicate information or facts to the pastor of the counselee’s local church they may do so.
-At any time during the counseling, for reasons sufficient to himself/herself, the counselor – as also the counselee – shall have the option of terminating counseling.
-If a conflict should arise between the counselee and the counselor, both parties must agree to resolve the dispute outside the secular court system. Conciliation will be sought under submission to and direction of the pastor(s) of CrossPoint Fellowship Church.

-If you are willing to enter into the kind of counseling described in this statement, please select yes.

yes no

Personal Data Inventory

Please fill in as much of this section as you are willing and able to do.

Personal Identification

Occupation

Birthdate

Age:

Gender: Male Female

Marital Status: Single Engaged Married Separated Divorced Remarried Widowed

If married, describe your current marriage (healthy, struggling, etc.)

Education: Elementary High School GED College Graduate

Degree:

Hobbies:

Employer:

Position: (include how long you've worked there)

Referred here by (include relationship):

Marriage and Family

Spouse:

Spouse's Birthdate:

Age:

Occupation:

How Long Employed:

Date of Marriage:

Length of Dating:

Give brief statement of circumstances of meeting and dating:

Have either of you been previously married:

To whom:

Have you ever been separated:

Filed for divorce:

Is your spouse willing to come for counseling:

Is your spouse in favor of your coming:

If no, please explain:

Please provide information about your children: (Names, Ages, Genders, Living?, Step-Child)

Describe your relationship with your father:

Describe your relationship with your mother:

Number of siblings with your sibling order:

Did you live with anyone other than your parents?

Are your parents living?

Health Information

Approximately how many hours of sleep do you get each night?

When do you go to sleep? When you get up?

Rate your health Very good Good Average Declining

List important illnesses and injuries or handicaps:

Do you have any chronic conditions? If so, what?

Date of last medical exam and report:

Physician's name and contact information:

Current medication(s) and dosage:

Have you ever seen a psychiatrist or counselor? If yes, please explain (include counselor/therapist, when, and outcome):

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records:

Have you used drugs for anything other than medical purposes? If so, please explain, list and share when the last time you used illegal drugs.

Do you drink alcoholic beverages? If so, how frequently and how much?

Do you drink coffee? How much?

Other caffeine drinks? How much?

Do you smoke, vape, or use tobacco products? Frequency?

Have you ever had interpersonal problems on the job? If yes, please explain:

In a few sentences, what kind of person are you? Describe yourself.

List fears you have:

Have you ever been arrested? If so, what was the length of your incarceration and what were you incarcerated for?

Spiritual

Denominational preference:

Church currently attending? Member?

Who is your pastor?

May we contact your pastor for background information?

Church attendance per month zero 1 2 3 4 5 6 7

Church attending in childhood:

Do you believe in God?

Do you pray?

Have you come to the place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?

Are you saved?

Have you ever been baptized?

How often do you read the Bible? Never Occasionally Often Daily

Does your family regularly read the Bible and pray together?

Explain any recent changes in your religious life, if any:

Financial

Approximate yearly family income:

Do you own your home?

Do you have significant debt in any of the following areas? Home, car, school, credit cards?

Are you saving money?

Do you give money to your church or other charities?

Is money a source of struggle or discomfort in your life?

Are you involved in or anticipate being involved in legal actions?

Women Only

Have you had any menstrual difficulties?

If you experience tension, tendency to cry, other symptoms prior to your cycle, please explain:

Your Information

We are grateful to the LORD for the opportunity to meet with you and sincerely desire to understand what is happening in your life. The below checklists and questions are a way for us to gather more information about what is going on. You can check as many boxes as you need, and your answers can be as long as you like but please write at least a few sentences for each question. Thank you for your help, and we will be prayerfully anticipating our meeting.

Please Tell Us Your "STOREE."

It will be helpful to have at least a few sentences or short paragraph for each letter of STOREE. Thank you for your help, and we will be prayerfully anticipating our meeting.

Situation: What seems to be the main problem?

Thinking: What do you think or wonder about yourself in relation to the situation? What do you think of others in relation to the situation?

Others: How are others involved? How does this issue impact others? What have others done to compound or alleviate the problem?

Response: What are you doing about this issue? What have you done to try to address this issue in the past? What are your typical actions or reactions to this problem (e.g. “I get angry and go for a drive”)? In general, when you are feeling pressure in life, how does it come out? What do you do? How are you sleeping?

Emotions: What do you fear? What would give you peace, related to this situation? What is the emotion you are struggling with the most?

Desires/Expectations: How do you hope we can help you? What do you want the most related to this situation?

Is there anything else we should know?

Counseling Intake Form

Description

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