Biblical Counseling Consent Form

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Terms and Conditions

Name*

First Name*

Last Name*

Confirmation - By checking the items below and completing the signature on this document, you indicate that you have read, understood, and agreed to these conditions:

Not Professional Advice - Although our staff and volunteer Lay Counselors may have been trained in professional fields, when serving the Biblical Counseling Ministry, they are providing Biblically based, spiritual insight.

I understand and accept

Focus of Ministry - Ministry focus and purpose is to address spiritual and heart issues using the Bible.

I understand and accept

Children - While the counseling is offered to you free of charge, we do not provide childcare. Bringing children under age 10 is not permissible.

I understand and accept

Appointments - Appointments are designed to be fifty (50) minutes.

I understand and accept

Cancelation and Rescheduling - If you have an appointment and cannot attend, you must notify us 24 hours in advance so that someone else who is in crisis may be scheduled for that appointment time.

I understand and accept

Confidentiality

Confidentiality is an important aspect of the Biblical counseling process. Information shared is confidential. The following illustrate if/when it may be necessary for us to share information with others:

If a staff/lay is uncertain how to address a particular problem and needs input from another counselor in this church
If content shared demands compliance with any and all state and/or federal laws, especially child abuse
If there is an indication that harm come to the participant or someone else (i.e. “duty to warn”)
If it is determined that a church authority has a need to know
If a person persistently refuses to renounce a particular sin. The assistance of others to encourage repentance and reconciliation become necessary. (see Proverbs 15:22, 24:11 and Matthew 18:15-20)
A person attends another church and it is necessary for us to talk with his or her pastor/staff regarding any issue which falls under any of the above (Galatians 6:1-2)

I understand and accept the Confidentiality agreement

Our Training Center - We are actively seeking to equip new counselors to minister to others. A “counselor in training" may observe a "Lead" Counselor by being present in a live session of observing from a secure remote classroom. Sessions may also be recorded for training purposes. A ‘Counselor in training’ is constrained by all the statements on this sheet, especially those pertaining to confidentiality.

I understand and accept

Resolution of Difficulties - On the rare occasion that a conflict arises between a counselee and a Biblical Counseling team member, to preserve integrity and purity for everyone, each counseling office is equipped with video recording of all activities and interactions. This allows us to review content, only as necessary, helping us to comply with Matthew 18:16, "...so that...every fact may be confirmed..." All recorded content is protect and will be utilized, only as necessary, for the stated purposes in this Informed Consent form. To ensure the conflict will be resolved in a Biblically faithful manner, we require all individuals to agree that any dispute will be settled by mediation. This is in accordance with the Rules of Procedure of the Institute for Christian Conciliation.

I understand and accept

We will be happy to provide to you the Christian Conciliation booklets describing its benefits and procedures

Statement of Faith - Bellevue Baptist Church has a continued, long-standing practice of striving to conduct only ceremonies and services, expecting only employee/volunteer conduct, and allowing only facility uses which are in harmony with our doctrinal beliefs as expressed in the Southern Baptist Convention’s most recent Statement of Faith. Believing that the privilege of guiding people to a knowledge of God’s Word and a total commitment to Christian discipleship is worthy of my surrender to God’s call of service, I covenant, as a participant in Bellevue’s Biblical Counseling, to conduct myself according to the beliefs and doctrines found in the Baptist Faith and Message. A copy of the Baptist Faith and Message will be provided upon request or can be accessed online at https://www.sbc.net/bfm2000/bfm2000.asp.

I understand and accept

Agreement - I will, under no circumstance, have the Biblical Counseling staff/ lay counselor or any notes conscribed during counseling sessions to be subpoenaed or require them to appear in court for legal suit regarding any matters disclosed/discussed during my participation in this ministry.

I understand and accept

Final - Having read ALL information fully and completely, I agree to discuss any questions I may have with the Biblical Counseling staff/lay counselor.

I understand and accept

My signature below indicates that I understand and fully agree to comply with all information.

Name*

First Name*

Last Name*

Signature*

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Parent/guardian signature*

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If participant is under 18

Date*

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Month

Day

Year

General Information

Participant Name

First Name

Last Name

I learned of this ministry by:

Friend Mail Brochure Advertisement Internet Other

I am seeking counseling for:

Date of Birth

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Month

Day

Year

Gender

Male Female

Address

Address Line 1

Address Line 2

City

State

ZIP Code

How long have you lived at this address?

Home Phone

Cell

Education (last completed)

Occupation

Employer

How long have you worked at your current place of employment?

Hours per week?

Do you enjoy your work?

Yes No

Relationships

Are you...

Married Divorced Separated Engaged Single Widowed

Spouse's name

How long have you been divorced?

# of previous marriages

Are you living together?

Yes No

How long?

Children

How many children do you have?

Child's name

First Name

Last Name

Child's age

Child's name

First Name

Last Name

Child's age

Child's name

First Name

Last Name

Child's age

Child's name

First Name

Last Name

Child's age

Child's name

First Name

Last Name

Child's age

How many children live in your home?

Other Counseling

Have you discussed the current issues with a professional?

Yes No

Name of counselor

First Name

Last Name

He/she is a:

Describe the results

Medical Issues

Describe any medical conditions

Are you on any medications?

Yes No

List the medication(s) and dose

Separate medications with a comma or forward slash ( / )

Are you currently on probation/court mandated treatment?

Yes No

Probation officer's name

First Name

Last Name

Reason(s) for probation

Are you willing to sign a release?

Yes No

If no, why?

Religion

We have found that a person's religious background has significant impact on how problems and conflict are handled. In order for us to be sensitive to your personal convictions, it is most helpful for you to share the following information.

I would describe my religion as:

My religious upbringing was:

Do you believe in God?

Yes No Unsure

I pray:

Daily Weekly Occasionally Never

Do you believe that you will be with God eternally when you die?

Yes No Unsure

Please share why or why not

Are you a member of a church?

Yes No

What's the name of your church?

What's the Pastor's name?

First Name

Last Name

How long have you been a member?

I attend church services:

Weekly Occasionally Never

Describe any church leadership positions you hold or activities you are involved in

Separate positions with a comma or forward slash ( / )

The person(s) who had the most influence on your religious/spiritual life is

Please give names and relationships

I read/study the Bible:

Daily Weekly Occasionally Never

My opinion of the Bible is:

I do not know enough about the Bible to state a clear opinion. A book, written by men, that contains principles and instructions that I am free to follow, or not follow, as I see fit. A book, inspired by God, that is His instructions and commands that I should follow regardless of my feelings or preferences. Other

Explain your opinion

I have had recent changes in my spiritual life:

Yes No

Explain any changes

Briefly describe the issues for which you are seeking help