PERSONAL INFORMATION FORMS

Hope is here! We all experience trouble, trials, battles with sin, and many other challenging situations as we walk through life. Selah International offers counseling based on God’s Word and dependent on the Holy Spirit which leads to Biblical change, hope, and healing. We have seen God work again and again in the lives of His children! If you are in need of help, please fill out one of our Personal Information Forms that applies to you. If you have questions, please reach out using the contact us form below.

Ministry Leader (USA)

Print PDF Form

Step 1 of 5

20%

Everyone needs biblical hope, care, and renewal in every stage of life, and God graciously supplies us with His sufficient hope and help (Rom. 15:4; 15:13). We consider it a great privilege to walk alongside you in your current season of life. By God’s grace, we desire to provide you with excellent biblical counseling care, and this “Personal Information” form helps us to accomplish this. Please fill out this form to the best of your ability, so that we may get to know you and your life situation. - SICM

General Information

Name:(Required)

First Last

Phone:(Required)

Address:(Required)

Street Address Unit / Suite Number City State Zip Code Country

Email Address:(Required)

Enter Email Confirm Email

Age:

Birth Date:

Sex:

Male

Female

Referred to us by:

Relationship to referrer:

Please list the best days and times you are available for counseling sessions between Monday-Friday:

Occupation(s):

Education:

Degree(s):

Other Training (Please list type and years):

Marital Status:

How many siblings do you have?

Older brothers

Older sisters

Younger brothers

Younger sisters

Marriage and Family Information

Name of Spouse:

First Last

Spouse's Phone:

Spouse's Age:

Spouse's Birth Date:

Spouse's Occupation(s):

Spouse's Education:

Spouse's Degree(s):

Degree(s):

Spouse's Other Training (Please list type and years):

Does your spouse know that you are coming for counseling?

Yes

Is your spouse willing to come for counseling?

Yes

Uncertain

Have you ever been separated?

Yes

Your ages when married:

Husband:

Wife:

Years married:

How long did you know your spouse before marriage?

Length of steady dating before marriage:

Length of enagagement:

How often do you spend meaningful time with your spouse?

Not often

Occasionally

Regularly

If applicable, please give any information about previous marriages:

Information about children:

*Please place a “PM” beside any children from a previous marriage*. *Please place an “NL” beside any children not living*. *Please place an “A” beside any adopted children*.

Name:

Birthdate:

Sex:

Education:

Marital Status:

Does your family regularly read the Bible and pray together?

Yes

Health Information

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

When do you go to sleep at night?

When do you get up?

Rate your health:

Excellent

Good

Average

Poor

Declining

Your approximate:

Weight:

Height:

Any weight changes recently?

Do you have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of your physician:

Are you presently taking medication?

Yes

Which medication(s)?

Have you ever used illegal or abused prescription drugs?

Yes

Which medications?

How often do you consume alcohol?

Daily

Weekly

Occasionally

Very little

None

If the counselor believes that it would be helpful to see your psychiatric and/or medical reports, would you be willing to sign an information release form?

Yes

How many times per week do you exercise? What type of exercise?

Do you have any dietary restrictions?

How would you rate your overall eating habits?

Poor

Good

Excellent

Religious Information

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

Yes

Uncertain

Suppose you died today, and God asked you: “Why should I let you into my heaven?” What would you say?

Have you been baptized?

Yes

How would you describe what God is like?

Number of days you read the Bible in any given week?

How often do you pray to God?

Rarely

Occasionally

Daily

What do you pray for?

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

Religious background of spouse:

Denominational preference:

Church attended in childhood:

City/State:

What church do you attend?

City/State:

Who is your pastor?

Do you have any other leaders in your church? (List their names and positions):

Do you consider yourself to be spiritually accountable to anyone? Who?

Number of church services you attend per month:

Personal Information

If you were raised by anyone other than your parents, please briefly explain:

What are some of your favorite things to do?

What does a typical day look like for you?

What relationships give you the most joy? The most sorrow?

What do you see as your greatest strength? Greatest weakness?

Check off any of the following words that best describe you now:

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Check off any of the following words which best describe you now:

Often sad

Self-conscious

Excitable

Imaginative

Calm

Serious

Easy going

Bitter

Shy

Fearful

Check off any of the following words which best describe you now:

Introvert

Extrovert

Likeable

Angry

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

Ministry Information

What do you see as the best or most fulfilling aspect of your present ministry?

What do you see as the most difficult or challenging aspect of your present ministry?

How often do you take personal time off or breaks from your ministry?

Who do you consider your closest companion(s) in your present ministry?

How long have you been in your present ministry? Any prior ministries?

History Information

Have you dealt with severe emotional struggles in the past or present?

Yes

Have you experienced any traumatic events?

Yes

Uncertain

If yes, what?

Have you ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your previous therapy/counseling?

At any time, have you:

Felt people were watching you?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

Have you ever been arrested?

Yes

If applicable, list reason for arrest:

List any fears or worries you have:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues you are struggling with at this time? When did you first begin to experience these problems?

What have you done about it? If you have spoken with anyone in leadership at your church, what have they recommended you do?

What do you hope is accomplished by coming to counseling at this time? (Your expectations?)

What circumstances led you to seek counsel here at this time?

What other information is important to your specific situation that you would like for us to know?

Distinctives and Consent to Counsel

Our Confidence in Biblical Counseling

At Selah International Counseling Ministries, we are confident that the Bible contains all the necessary information for your life and your need for godliness (2 Peter 1:2-4). We do not need to go outside its pages to find the answers. Though it is not a medical book, it is a spiritual, relational, and behavioral Book from God Himself. When God’s Word speaks to our problem or trouble, it is the authority in explaining why the problem exists. There is no other book or counsel so worthy of our attention as we seek explanations and solutions to all our woes. Those who put their hope in His Word will never be ashamed. If we follow His counsel, we will always be led in the right way – to a deeper faith and practical obedience in Jesus Christ. Simply stated, the Bible guides us through our problems to Jesus Christ. There is not and never will be another counselor more wise, more powerful, more loving, more insightful, and more worthy than Him. In Him, we will find all we need. He is sufficient and His Word is sufficient in leading us to Him.

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Please bring your Bible and notebook to take notes, ready to prayerfully work on specific changes God’s Word prescribes for you. You will be asked to complete homework between sessions. Each assignment will be relevant to your presenting problem and will help you find biblical resolution more quickly.

It is important for you to attend a local Christian church that believes and teaches God’s Word clearly and unashamedly. Fellowship with God’s people is essential to promoting and sustaining the things God will be doing in your life through biblical counseling. In some cases, and with your approval, we will ask a Pastor or another mature Christian or to join us in the counseling process for the purpose of supporting you more personally through prayer and a caring relationship.

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Please be assured that our counselors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible.

Cost

It costs Selah International $130 per session to provide this level of personalized counseling and solutions. If two counselors are needed, that cost grows to $160 per session. However, we do not want financial reasons to keep anyone from receiving biblical counseling. If the cost of counseling is a concern, we have a limited number of scholarships available for those in full-time ministry. Please contact us directly for more information regarding these scholarships at admin@selahinternational.org. You will be billed weekly after your sessions take place. Please note that we require a notification of one, full business day before a cancellation or rescheduling of an appointment. The only exceptions are in the case of an emergency. If sufficient notice is not given, we will invoice you for $40 to help cover the lost time by the counselor.

Consent

I agree

I agree not to subpoena or require any biblical counselor to appear in any legal proceedings related to any matters or any persons discussed in any counseling appointments; Furthermore, I agree not to attempt to subpoena any notes or records related to the counseling process.

Consent

I agree

I understand that I may be asked to allow two counselors to work together with me on helping me find biblical solutions to the problems. This is because of the benefits to the counselees that this team approach has produced. The primary counselor will be a staff biblical counselor, but a team counselor may join him.

Consent

I agree

I understand SICM counselors do not use psychological models or insights to help me with explaining or solving my problems. I understand that SICM counselors are biblically trained and certified to counsel. I understand SICM seeks to use the Scriptures to interpret, instruct, and inspire solutions.

Consent

I agree

I understand that depending on the presenting issue(s) involved, recommendations for spiritual accountability and transparency with church authority may need to be implemented for ongoing counseling.

Consent

I agree

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Untitled

Counselee's Name

Online Signature

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Ministry Leader (International)

Print PDF Form

Step 1 of 5

20%

General Information

Name:(Required)

First Last

Phone:(Required)

Address:

Street Address Unit / Suite Number City State (if applicable) Zip Code Country

Email Address:(Required)

Enter Email Confirm Email

Age:

Birth Date:

Sex:

Male

Female

Referred to us by:

Relationship to referrer:

Please list the best days and times you are available for counseling sessions between Monday-Friday:

Occupation(s):

Education:

Degree(s):

Other Training (Please list type and years):

Marital Status:

How many siblings do you have?

Older brothers

Older sisters

Younger brothers

Younger sisters

Marriage and Family Information

Name of Spouse:

First Last

Spouse's Phone:

Spouse's Age:

Spouse's Birth Date:

Spouse's Occupation(s):

Spouse's Education:

Degree(s):

Spouse's Other Training (Please list type and years):

Does your spouse know that you are coming for counseling?

Yes

Is your spouse willing to come for counseling?

Yes

Uncertain

Have you ever been separated?

Yes

If so, when?

Your ages when married:

Husband:

Wife:

Years married:

How long did you know your spouse before marriage?

Length of steady dating before marriage:

Length of enagagement:

How often do you spend meaningful time with your spouse?

Not often

Occasionally

Regularly

If applicable, please give any information about previous marriages:

Information about children:

*Please place a “PM” beside any children from a previous marriage*. *Please place an “NL” beside any children not living*. *Please place an “A” beside any adopted children*.

Name:

Birthdate:

Sex:

Education:

Marital Status:

Does your family regularly read the Bible and pray together?

Yes

Do you have any immediate family members currently living in another country?

Health Information

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

When do you go to sleep at night?

When do you get up?

Rate your health:

Excellent

Good

Average

Poor

Declining

Your approximate:

Weight:

Height:

Any weight changes recently?

Do you have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of your physician:

Are you presently taking medication?

Yes

Which medication(s)?

Have you ever used illegal or abused prescription drugs?

Yes

Which medications?

How often do you consume alcohol?

Daily

Weekly

Occasionally

Very little

None

If the counselor believes that it would be helpful to see your psychiatric and/or medical reports, would you be willing to sign an information release form?

Yes

How many times per week do you exercise? What type of exercise?

Do you have any dietary restrictions?

How would you rate your overall eating habits?

Poor

Good

Excellent

Religious Information

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

Yes

Uncertain

Suppose you died today, and God asked you: “Why should I let you into my heaven?” What would you say?

Have you been baptized?

Yes

How would you describe what God is like?

Number of days you read the Bible in any given week:

How often do you pray to God?

Rarely

Occasionally

Daily

What do you pray for?

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

Religious background of spouse:

Denominational preference:

Church attended in childhood:

City/State:

Sending church (if applicable):

City/State:

Sending church pastor’s name:

Name of mission board/agency:

Name of church you attend:

City/State:

Name of Pastor:

Do you have any other leaders in your church? (List their names and positions):

Do you consider yourself to be spiritually accountable to anyone? Who?

Number of church services you attend per month:

Personal Information

If you were raised by anyone other than your parents, please briefly explain:

What languages do you speak? How fluently?

What ares some of your favorite things to do?

What does a typical day look like for you?

What relationships give you the most joy? The most sorrow?

What do you see as your greatest strength? Greatest weakness?

Check off any of the following words that best describe you now:

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Check off any of the following words which best describe you now:

Often sad

Self-conscious

Excitable

Imaginative

Calm

Serious

Easy going

Bitter

Shy

Fearful

Check off any of the following words which best describe you now:

Introvert

Extrovert

Likeable

Angry

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

Ministry Information

What do you see as the best or most fulfilling aspect of your present ministry?

What do you see as the most difficult or challenging aspect of your present ministry?

How often do you take personal time off or breaks from your ministry?

Who do you consider your closest companion(s) in your present ministry?

How long have you been in your present ministry? Any prior ministries?

History Information

Have you dealt with severe emotional struggles in the past or present?

Yes

Have you experienced any traumatic events?

Yes

Uncertain

If yes, what?

Have you ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your previous therapy/counseling?

At any time, have you:

Felt people were watching you?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

Have you ever been arrested?

Yes

If applicable, list reason for arrest:

List any fears or worries you have:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues you are struggling with at this time? When did you first begin to experience these problems?

What have you done about it? If you have spoken with anyone in leadership at your church, what have they recommended you do?

What do you hope is accomplished by coming to counseling at this time? (Your expectations?)

What circumstances led you to seek counsel here at this time?

What other information is important to your specific situation that you would like for us to know?

Distinctives and Consent to Counsel

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree

Consent

I agree

Consent

I agree

Consent

I agree

I understand that depending on the presenting issue(s) and the circumstances involved, my sending pastor and/or missions agency area
director may need to be appropriately informed of your counseling relationship with SICM within a time frame determined by your counselor. I understand that my counselor will clearly communicate with me prior to initiating contact with my sending pastor and/or missions agency area director.

Consent

I agree

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Please inform SICM of specific communication instructions if security concerns exist for transmission of sensitive information online. While SICM seeks to be confidential in its storage of sensitive information, we cannot guarantee complete security of information that is transmitted online.

Counselee's Name

Online Signature

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Parent of Child (USA)

Print PDF Form

Step 1 of 6

16%

Family Information

Child's Information:

Name:(Required)

First Last

Age:

Birth Date:

Sex:

Male

Female

Grade:

Referred to us by:

Relationship to referrer:

Father's Information:

Name:(Required)

First Last

Age:

Address:(Required)

Street Address Unit / Suite Number City State Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Mother's Information:

Name:(Required)

First Last

Age:

Address (if different from Father’s address):

Street Address Unit / Suite Number City State Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Marriage and Children Information:

Marital Status:

Have you ever been separated?

Yes

If so, when?

From:

Till:

Your ages when married:

Husband:

Wife:

Years married:

How long did you know your spouse before marriage?

Length of steady dating before marriage:

Length of enagagement:

If applicable, please give any information about previous marriages:

Do both biological parents live with the child coming for counseling?

Yes

Are either of you a stepparent?

Who is the child’s custodian/guardian(s)?

Information about children:

*Please place a “PM” beside any children from a previous marriage*. *Please place an “NL” beside any children not living*. *Please place an “A” beside any adopted children*.

Name:

Birthdate:

Sex:

Education:

Marital Status:

Who currently lives in the same household as the child? (Please list all persons, including any house guests or extended relatives.)

Does your family regularly read the Bible and pray together?

Yes

Your Child's Health Information

Approximately how many hours of sleep does he/she get each night?

When does he/she go to sleep at night?

When does he/she get up?

Rate his/her health:

Excellent

Good

Average

Poor

Declining

His/her approximate:

Weight:

Height:

Any weight changes recently?

Does he/she have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of his/her physician

Is he/she presently taking medication?

Yes

Which medication(s)?

Has he/she ever used illegal or abused prescription drugs?

Yes

Unsure

If the counselor believes that it would be helpful to see his/her psychiatric and/or medical reports, would you be willing to sign a release of information form?

Yes

How many times per week does he/she exercise? What type of exercise?

Does he/she have any dietary restrictions?

How would you rate his/her overall eating habits?

Poor

Good

Excellent

Parents' Religious Information:

Have both you and your spouse repented of your sin and placed your faith in Christ? When?

Have both you and your spouse been baptized? When?

Personal Church Information

Name of church you attend:

City/State:

Name of pastor:

Do you have any other leaders in your church? (List their names and positions):

Denominational preference:

Do both you and your spouse regularly attend church together?

Yes

Number of church services your family attends per month:

Do both parents regularly spend personal time in God’s Word and in prayer?

Yes

Please explain any changes in your spiritual life or your spouse’s spiritual life, if any:

Your Child's Religious Information

Does your child believe in God?

Yes

Has your child repented of his/her sin and placed his/her faith in Christ? When?

Has your child been baptized? When?

Is there evidence of faith and a walk with Christ in your child in the past? In the present? Please explain your answer to the best of your ability:

Explain any recent changes in your child’s religious life, if any?

Your Child's Personal Information

If your child was raised by anyone other than his/her biological parents, please briefly explain:

Where does your child attend school?

Who are your child’s closest companions?

What do you see as your child’s greatest strength? Greatest weakness?

How does your child handle stress?

Please provide a brief timeline and explanation of any major/impactful events in your child’s life:

Check off any of the following words which best describe your child now:

Check off any of the following words which best describe you now:

Introvert

Extrovert

Likeable

Angry

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

Check off any of the following words that best describe you now:

Often sad

Self-conscious

Excitable

Imaginative

Calm

Serious

Easy going

Bitter

Shy

Fearful

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Your Child's History Information

Has your child dealt with severe emotional struggles in his/her past or present?

Yes

Has your child experienced any traumatic events?

Yes

Uncertain

If yes, what?

Has your child ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your child’s previous therapy/counseling?

At any time, has your child:

Felt people were watching him/her?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

List any fears or worries your child has about which you are aware:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues your child is struggling with at this time? When did he/she first begin to experience these problems? Is this a time of crisis?

What has he/she done about it? What have you as parents done about it?

Has anyone in the family experienced similar problems?

What do you hope to be accomplished by bringing your child to counseling at this time? What are your expectations?

What other information is important to you and your child’s situation that you would like for us to know?

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Child's printed name:

Parent/guardian name:

Online Signature:

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Parent of Child (International)

Print PDF Form

Step 1 of 6

16%

Identification Data

Child's Information:

Name:(Required)

First Last

Age:

Birth Date:

Sex:

Male

Female

Grade:

Referred to us by:

Relationship to referrer:

Please list the days and times your child is available for counseling sessions Monday-Friday:

Father's Information:

Name:(Required)

First Last

Age:

Address:

Street Address Unit / Suite Number City State (if applicable) Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Mother's Information:

Name:(Required)

First Last

Age:

Address (if different from Father’s address):

Street Address Unit / Suite Number City State(if applicable) Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Marriage and Children Information:

Marital Status:

Have you ever been separated?

Yes

If so, when?

From:

Till:

Your ages when married:

Husband:

Wife:

Years married:

How long did you know your spouse before marriage?

Length of steady dating before marriage:

Length of enagagement:

If applicable, please give any information about previous marriages:

Do both biological parents live with the child coming for counseling?

Yes

Are either of you a stepparent?

Who is the child’s custodian/guardian(s)?

Information about children:

*Please place a “PM” beside any children from a previous marriage*. *Please place an “NL” beside any children not living*. *Please place an “A” beside any adopted children*.

Name:

Birthdate:

Sex:

Education:

Marital Status:

Who currently lives in the same household as the child? (Please list all persons, including any house guests or extended relatives.)

Does your family regularly read the Bible and pray together?

Yes

Do you have any immediate family members currently living in another country?

Your Child's Health Information

Approximately how many hours of sleep does he/she get each night?

When does he/she go to sleep at night?

When does he/she get up?

Rate his/her health:

Excellent

Good

Average

Poor

Declining

His/her approximate:

Weight:

Height:

Any weight changes recently?

Does he/she have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of his/her physician:

Is he/she presently taking medication?

Yes

Which medication(s)?

Has he/she ever used illegal or abused prescription drugs?

Yes

Unsure

If the counselor believes that it would be helpful to see his/her psychiatric and/or medical reports, would you be willing to sign a release of information form?

Yes

How many times per week does he/she exercise? What type of exercise?

Does he/she have any dietary restrictions?

How would you rate his/her overall eating habits?

Poor

Good

Excellent

Parents' Religious Information:

Have both you and your spouse repented of your sin and placed your faith in Christ? When?

Have both you and your spouse been baptized? When?

Sending Church Information(if applicable):

Sending church (if applicable):

City/State:

Sending church pastor’s name:

Mission Board/Agency Information:

Name of mission board/agency:

City/State:

Personal Church Information:

Name of church you attend:

City/State:

Name of pastor:

Do you have any other leaders in your church? (List their names and positions):

Denominational preference:

Do both you and your spouse regularly attend church together?

Yes

Number of church services your family attends per month:

Do both parents regularly spend personal time in God’s Word and in prayer?

Yes

Please explain any changes in your spiritual life or your spouse’s spiritual life, if any:

Your Child's Religious Information

Does your child believe in God?

Yes

Uncertain

Has your child repented of his/her sin and placed his/her faith in Christ? When?

Has your child been baptized? When?

Is there evidence of faith and a walk with Christ in your child in the past? In the present? Please explain your answer to the best of your ability:

Explain any recent changes in your child’s spiritual life, if any:

Your Child's Personal Information

If your child was raised by anyone other than his/her biological parents, please briefly explain:

Was your child born and raised in the place of your current ministry?

Yes

If not, please list the age of your child at the time when your family relocated to the place of your current ministry:

Where does your child attend school?

Does your child speak any foreign languages? How fluently?

Who are your child’s closest companions?

What do you see as your child’s greatest strength? Greatest weakness?

How does your child handle stress?

Please provide a brief timeline and explanation of any major/impactful events in your child’s life:

Check off any of the following words that best describe your child now:

Check off any of the following words which best describe you now:

Introvert

Extrovert

Likeable

Angry

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

Check off any of the following words which best describe you now:

Often sad

Self-conscious

Excitable

Imaginative

Calm

Serious

Easy going

Bitter

Shy

Fearful

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Your Child's History Information

Has your child dealt with severe emotional struggles in his/her past or present?

Yes

Has your child experienced any traumatic events?

Yes

Uncertain

If yes, what?

Has your child ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your child’s previous therapy/counseling?

At any time, has your child:

Felt people were watching him/her?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

List any fears or worries your child has about which you are aware:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues your child is struggling with at this time? When did he/she first begin to experience these problems? Is this a time of crisis?

What has he/she done about it? What have you as parents done about it?

Has anyone in the family experienced similar problems?

What do you hope to be accomplished by bringing your child to counseling at this time? What are your expectations?

What other information is important to you and your child’s situation that you would like for us to know?

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Counselee's Name:

Parent/Guardian Name:

Online Signature

Date

MM slash DD slash YYYY

Captcha

COACHING

Print PDF Form

Coaching PIF

Step 1 of 5

20%

Everyone needs biblical hope, care, and renewal in every stage of life, and God graciously supplies us with His sufficient hope and help (Rom. 15:4; 15:13). We consider it a great privilege to walk alongside you as you care for your flock. By God’s grace, we desire to provide you with excellent coaching in biblical counseling, and this “Coaching Form” form helps us to accomplish this. Please fill out this form to the best of your ability, so that we may get to know you and the counseling situation you are faced with at this time. - SICM

General Information

Name:(Required)

First Last

Phone:(Required)

Address:

Street Address Unit / Suite Number City State (if applicable) Zip Code Country

Email Address:(Required)

Enter Email Confirm Email

Age:

Birth Date:

Sex:

Male

Female

Occupation(s) (Ministry and/or other):

Do you have any other leaders in your church? (List their names and positions):

Your Counselee's General Information

First names of those receiving counsel:

Age:

Sex:

Male

Female

Age:

Sex:

Male

Female

Others who will receive counsel:

What is their occupation(s)?

Are the counselee(s) in any way related to you?

Do they serve in a particular paid or volunteer position in your church?

In what ways are they active in your church?

Your Counselee's Marriage and Family Information

Marital Status:

Name of Spouse:

First Last

Age of spouse:

How many siblings do you have?

Older brothers

Older sisters

Younger brothers

Younger sisters

Are both spouses willing to come for counseling?

Yes

Uncertain

To your knowledge, has there been any abuse in the relationship?

Yes

Uncertain

To your knowledge, is the couple currently separated, or have they spoken about separating/divorce?

Yes

Uncertain

How many children do they have?

Are any children from a previous marriage or adopted?

Is there any other important information regarding their marriage that you believe we should know?

Your Counselee's Health Information

Is there any important information regarding your counselee’s health that we should know?

Your Counselee's Religious Information

Do you believe that your counselee has repented of their sin and placed their faith in Jesus Christ for salvation?

Yes

Uncertain

Any explanation needed?

Have they been baptized?

Yes

Any explanation needed?

Are they a member of your church?

Yes

Any explanation needed?

How would you describe their personal walk with the Lord? (including Bible-reading and prayer habits)

Your Counselee's History Information

Have they dealt with severe emotional struggles in the past or present?

Yes

Uncertain

Have they experienced any traumatic events?

Yes

Uncertain

If yes, what?

Have they ever had any therapy or counseling before?

Yes

Uncertain

Please list any details you are aware of regarding the therapy or counsel given previously:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues that they are struggling with at this time?

Is this a time of crisis?

What counsel have you given? What have you recommended that they do?

How do you believe that we can best come alongside you in this situation?

Is there any other information about this situation that you would like for us to know?

Distinctives and Consent to Counsel

Our Confidence in Biblical Counseling

At Selah International Counseling Ministries, we are confident that the Bible contains all the necessary information for life and godliness (2 Peter 1:24). We do not need to go outside its pages to find the answers. Though it is not a medical book, it is a spiritual, relational, and behavioral Book from God Himself. When God’s Word speaks to our problem or trouble, it is the authority in explaining why the problem exists. There is no other book or counsel so worthy of our attention as we seek explanations and solutions to all our woes. Those who put their hope in His Word will never be ashamed. If we follow His counsel, we will always be led in the right way – to a deeper faith and practical obedience in Jesus Christ. Simply stated, the Bible guides us through our problems to Jesus Christ. There is not and never will be another counselor more wise, more powerful, more loving, more insightful, and more worthy than Him. In Him, we will find all we need. He is sufficient and His Word is sufficient in leading us to Him.

What You Can Expect

You will receive coaching on how to carefully gather all the information needed to understand your counselee’s unique situation.
You will receive coaching on how to offer biblical hope and encouragement to your counselee(s) that their problems can be solved.
You will receive coaching on gaining biblical insights into the root causes of your counselee’s problems.
You will receive coaching on how to help your counselee(s) learn to think and respond to their trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Please have your Bible and notebook/computer available to take notes (whether in person or virtual), ready to prayerfully discuss and work through your unique counseling situation and biblical resolutions for your counselee(s).

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others.
When there is a clear indication that someone may be physically or sexually abused unless others intervene.
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation. (Proverbs 15:22; 24:11; Matthew 18:15-20)

Please be assured that our coaches and counselors strongly prefer not to disclose personal information to others, and they will make every effort to help you and your counselee(s) find ways to resolve a problem as privately as possible.

Cost

Consent

I agree

I agree not to subpoena or require any coach or biblical counselor to appear in any legal proceedings related to any matters or any persons discussed in any coaching or counseling appointments; Furthermore, I agree not to attempt to subpoena any notes or records related to the coaching or counseling process.

Consent

I agree

I understand SICM coaches and counselors do not use psychological models or insights to help with explaining or solving problems. I understand that SICM coaches and counselors are biblically trained and certified to counsel. I understand SICM seeks to use the Scriptures to interpret, instruct, and inspire solutions.

Consent

I agree

I understand that depending on the presenting issue(s) involved, recommendations for spiritual accountability and transparency with church authority may need to be implemented for ongoing coaching and counseling.

Consent

I agree

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Counselee's Name

Online Signature

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Teen (USA)

Print PDF Form

Step 1 of 5

20%

General Information

Name:(Required)

First Last

Phone:(Required)

Address:(Required)

Street Address Unit / Suite Number City State Zip Code Country

Email Address:(Required)

Enter Email Confirm Email

Age:

Birth Date:

Sex:

Male

Female

Grade:

Referred to us by:

Relationship to referrer:

Please list the days and times you are available for counseling sessions between Monday-Friday:

Do you have a job or do any specific kind of work?

Where do you go to school?

Family Information

Name of Father:

First Last

Name of Mother:

First Last

Father's Phone:

Mother's Phone:

Parents' email address:

Parents' Occupation(s):

Parents’ Marital Status:

Do both parents know you are coming for counseling?

Yes

Are either of your parents a stepparent?

If yes, who do you live with?

If you were raised by anyone other than your parents, please briefly explain:

Siblings:

Older brothers:

Older sisters:

Younger brothers:

Younger sisters:

Does your family regularly read the Bible and pray together?

Yes

Who currently lives in the same household as you? (Please list all persons, including any house guests or extended relatives.)

Health Information

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

When do you go to sleep at night?

When do you get up?

Rate your health:

Excellent

Good

Average

Poor

Declining

Your approximate

Weight:

Height:

Any weight changes recently?

Do you have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of your physician:

Are you presently taking medication?

Yes

Which medication(s)?

Have you ever used illegal or abused prescription drugs?

Yes

Which medication(s)?

How often do you consume alcohol?

Daily

Weekly

Occasionally

Very little

None

How many times per week do you exercise? What type of exercise?

Do you have any dietary restrictions?

How would you rate your overall eating habits?

Poor

Good

Excellent

Religious Information

Do you believe in God?

Yes

Uncertain

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

Yes

Uncertain

Suppose you died today, and God asked you: “Why should I let you into my heaven?” What would you say?

Have you been baptized?

Yes

How would you describe what God is like?

Number of days you read the Bible in any given week:

How often do you pray to God?

Rarely

Occasionally

Daily

What do you pray for?

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

Church attended in childhood:

City/State:

Do you attend the same church as your parents?

Yes

Name of church you attend:

City/State:

Name of Pastor:

Do you consider yourself to be spiritually accountable to anyone? Who?

What is the number of church services you attend per month?

Personal Information

What does a typical day look like for you?

What are your goals in life?

What do you think you need?

What do you see as your greatest strength? Greatest weakness?

Check off any emotions you feel frequently:

Check off any of the following words which best describe you now:

Bored

Aggressive

Sad

Helpless

Content

Hyper

Sorry

Crazy

Positive

Anxious

Ashamed

Proud

Check off any of the following words which best describe you now:

Confused

Frustrated

Calm

Guilty

Disappointed

Afraid

Peaceful

Stubborn

Regret

Shy

Happy

Embarrassed

Check off any of the following words which best describe you now:

Angry

Friendly

Negative

Loved

Discouraged

Excited

Getting To Know You

What are your favorite subjects?

What are your least favorite subjects?

What extracurricular activities do you do?

What are your favorite things to do?

What are your least favorite things to do?

What are you good at?

What are you not good at?

When you are alone, what do you think about?

When do you feel happy?

What do you worry about?

When do you feel sad?

Finish this sentence: I can share my feelings better when

Who are your favorite people to be with?

Who do you find it hard to spend time with?

Who do you spend the most time with?

What do you like to do with your family?

What do you not like to do with your family?

Who do you look up to? Why?

What do you not like to tell other people?

When is it easy to talk to others?

Finish this sentence: I wish other people would

Who are your safe people?

Who are your unsafe people?

Check off any of the following words that best describe you now:

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Often

Sad

Self-conscious

Check off any of the following words which best describe you now:

Excitable

Imaginative

Calm

Serious

Easy-going

Bitter

Shy

Fearful

Introvert

Extrovert

Likeable

Angry

Check off any of the following words which best describe you now:

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

History Information

Have you dealt with severe emotional struggles in the past or present?

Yes

Have you experienced any traumatic events?

Yes

Uncertain

If yes, what?

Have you ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your previous therapy/counseling?

At any time, have you:

Felt people were watching you?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

Have you ever been arrested?

Yes

If applicable, list reason for arrest:

List any fears or worries you have:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues you are struggling with at this time? When did you first begin to experience these problems?

What have you done about it?

What do you hope is accomplished by coming to counseling at this time? (Your expectations?)

What circumstances led you to seek counsel here at this time?

What other information is important to your specific situation that you would like for us to know?

Distinctives and Consent to Counsel

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree

Consent

I agree

Consent

I agree

Consent

I agree

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Counselee's Name:

Parent/Guardian's Name:

Online Signature:

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Teen (International)

Print PDF Form

Step 1 of 5

20%

General Information

Name:(Required)

First Last

Phone:(Required)

Address:

Street Address Unit / Suite Number City State (if applicable) Zip Code Country

Email Address:(Required)

Enter Email Confirm Email

Age:

Birth Date:

Sex:

Male

Female

Referred to us by:

Relationship to referrer:

Please list the best days and times you are available for counseling sessions between Monday-Friday:

Do you have a job or do any specific kind of work?

Where do you go to school?

Family Information

Name of Father:

First Last

Name of Mother:

First Last

Father's Phone:

Mother's Phone:

Parents' email address:

Parents' Occupation(s):

Parents’ Marital Status:

Do both parents know you are coming for counseling?

Yes

Are either of your parents a stepparent?

If yes, who do you live with?

If you were raised by anyone other than your parents, please briefly explain:

Siblings:

Older brothers:

Older sisters

Younger brothers:

Younger sisters:

Does your family regularly read the Bible and pray together?

Yes

Do you have any immediate family members currently living in another country?

Who currently lives in the same household as you? (Please list all persons, including any house guests or extended relatives.)

Health Information

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

When do you go to sleep at night?

When do you get up?

Rate your health:

Excellent

Good

Average

Poor

Declining

Your approximate:

Weight:

Height:

Any weight changes recently?

Do you have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of your physician:

Are you presently taking medication?

Yes

Which medication(s)?

Have you ever used illegal or abused prescription drugs?

Yes

Which medication(s)?

How often do you consume alcohol?

Daily

Weekly

Occasionally

Very little

None

How many times per week do you exercise? What type of exercise?

Do you have any dietary restrictions?

How would you rate your overall eating habits?

Excellent

Good

Poor

Religious Information

Do you believe in God?

Yes

Uncertain

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

Yes

Uncertain

Suppose you died today, and God asked you: “Why should I let you into my heaven?” What would you say?

Have you been baptized?

Yes

How would you describe what God is like?

Number of days you read the Bible in any given week:

How often do you pray to God?

Rarely

Occasionally

Daily

What do you pray for?

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

Church attended in childhood:

Do you attend the same church as your parents?

Yes

City/State:

What church do you attend?

City/State:

Who is your pastor?

Do you consider yourself to be spiritually accountable to anyone? Who?

What is the number of church services you attend per month?

Personal Information

What languages do you speak? How fluently?

What does a typical day look like for you?

What are your goals in life?

What do you think you need?

What do you see as your greatest strength? Greatest weakness?

Check off any emotions you feel frequently:

Check off any of the following words which best describe you now:

Bored

Aggressive

Sad

Helpless

Content

Hyper

Sorry

Crazy

Positive

Anxious

Ashamed

Proud

Check off any of the following words which best describe you now:

Confused

Frustrated

Calm

Guilty

Disappointed

Afraid

Peaceful

Stubborn

Regret

Shy

Happy

Embarrassed

Check off any of the following words which best describe you now:

Angry

Friendly

Negative

Loved

Discouraged

Excited

Getting To Know You

What are your favorite subjects?

What are your least favorite subjects?

What extracurricular activities do you do?

What are your favorite things to do?

What are your least favorite things to do?

What are you good at?

What are you not good at?

When you are alone, what do you think about?

When do you feel happy?

What do you worry about?

When do you feel sad?

Finish this sentence: I can share my feelings better when

Who are your favorite people to be with?

Who do you find it hard to spend time with?

Who do you spend the most time with?

What do you like to do with your family?

What do you not like to do with your family?

Who do you look up to? Why?

What do you not like to tell other people?

When is it easy to talk to others?

Finish this sentence: I wish other people would

Who are your safe people?

Who are your unsafe people?

Check off any of the following words that best describe you now:

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Often

Sad

Self-conscious

Check off any of the following words which best describe you now:

Excitable

Imaginative

Calm

Serious

Easy-going

Bitter

Shy

Fearful

Introvert

Extrovert

Likeable

Angry

Check off any of the following words which best describe you now:

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

History Information

Have you dealt with severe emotional struggles in the past or present?

Yes

Have you experienced any traumatic events?

Yes

Uncertain

If yes, what?

Have you ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your previous therapy/counseling?

At any time, have you:

Felt people were watching you?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

Have you ever been arrested?

Yes

If applicable, list reason for arrest:

List any fears or worries you have:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues you are struggling with at this time? When did you first begin to experience these problems?

What have you done about it?

What do you hope is accomplished by coming to counseling at this time? (Your expectations?)

What circumstances led you to seek counsel here at this time?

What other information is important to your specific situation that you would like for us to know?

Distinctives and Consent to Counsel

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree

Consent

I agree

Consent

I agree

Consent

I agree

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Counselee's Name

Parent/Guardian Name

Online Signature

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Parent of Teen (USA)

Print PDF Form

Step 1 of 6

16%

Family Information:

Teen's Information:

Name:(Required)

First Last

Age:

Birth Date:

Sex:

Male

Female

Grade:

Referred to us by:

Relationship to referrer:

Please list the best days and times your child is available for counseling sessions between Monday-Friday:

Father's Information:

Name:(Required)

First Last

Age:

Address:(Required)

Street Address Unit / Suite Number City State Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Mother's Information:

Name:(Required)

First Last

Age:

Address(if different than Father's address):

Street Address Unit / Suite Number City State Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Marriage and Children Information:

Marital Status:

Have you ever been separated?

Yes

If so, when?

From:

Till:

Your ages when married:

Husband:

Wife:

Years married:

How long did you know your spouse before marriage?

Length of steady dating before marriage:

Length of enagagement:

If applicable, please give any information about previous marriages:

Do both biological parents live with the teen coming for counseling?

Yes

Are either of you a stepparent?

Who is the teen's custodian/guardian(s)?

Information about children:

*Please place a “PM” beside any children from a previous marriage*. *Please place an “NL” beside any children not living*. *Please place an “A” beside any adopted children*.

Name:

Birthdate:

Sex:

Education:

Marital Status:

Who currently lives in the same household as the teen? (Please list all persons, including any house guests or extended relatives.)

Does your family regularly read the Bible and pray together?

Yes

Your Teen's Health Information

Approximately how many hours of sleep does he/she get each night?

When does he/she go to sleep at night?

When does he/she get up?

Rate his/her health:

Excellent

Good

Average

Poor

Declining

His/her approximate:

Weight:

Height:

Any weight changes recently?

Does he/she have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of his/her physician:

Is he/she presently taking medication?

Yes

Which medication(s)?

Has he/she ever used illegal or abused prescription drugs?

Yes

Unsure

If the counselor believes that it would be helpful to see his/her psychiatric and/or medical reports, would you be willing to sign a release of information form?

Yes

How many times per week does he/she exercise? What type of exercise?

Does he/she have any dietary restrictions?

How would you rate his/her overall eating habits?

Poor

Good

Excellent

Parents' Religious Information:

Have both you and your spouse repented of your sin and placed your faith in Christ? When?

Have both you and your spouse been baptized? When?

Personal Church Information

Name of church you attend:

City/State:

Name of pastor:

Do you have any other leaders in your church? (List their names and positions):

Denominational preference:

Do both you and your spouse regularly attend church together?

Yes

Number of church services your family attends per month:

Do both parents regularly spend personal time in God’s Word and in prayer?

Yes

Explain any recent changes in your spiritual life or your spouse’s spiritual life, if any:

Your Teen's Religious Information

Does your teen believe in God?

Yes

Uncertain

Has your teen repented of his/her sin and placed his/her faith in Christ? When?

Has your teen been baptized? When?

Does your teen attend the same church as you?

Yes

If not,

What church does your teen attend?

City/State:

Is there evidence of faith and a walk with Christ in your teen in the past? In the present? Please explain your answer to the best of your ability:

Explain any recent changes in your teen's spiritual life, if any?

Your Teen's Personal Information

If your teen was raised by anyone other than your parents, please briefly explain:

Where does your teen attend school?

Who are your teen’s closest companions?

What do you see as your teen’s greatest strength? Greatest weakness?

How does your teen handle stress?

Please provide a brief timeline and explanation of any major/impactful events in your teen’s life:

Check off any of the following words which best describe your teen now:

Check off any of the following words which best describe you now:

Introvert

Extrovert

Likeable

Angry

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

Check off any of the following words which best describe you now:

Often sad

Self-conscious

Excitable

Imaginative

Calm

Serious

Easy going

Bitter

Shy

Fearful

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Your Teen's History Information

Has your teen dealt with severe emotional struggles in his/her past or present?

Yes

Has your teen experienced any traumatic events?

Yes

Uncertain

If yes, what?

Has your teen ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your teen’s previous therapy/counseling?

At any time, has your teen:

Felt people were watching them?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

Has your teen ever been arrested?

Yes

If so, please list reason for arrest:

List any fears or worries your teen has about which you are aware:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues your teen is struggling with at this time? When did he/she first begin to experience these problems? Is this a time of crisis?

What has he/she done about it? What have you as parents done about it?

Has anyone in the family experienced similar problems?

What do you hope to be accomplished by bringing your teen to counseling at this time? What are your expectations?

What other information is important to you and your teen’s situation that you would like for us to know?

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Counselee's Name:

Parent/Guardian's Name

Online Signature

Date

MM slash DD slash YYYY

Please type the characters shown

Captcha

Parent of Teen (International)

Print PDF Form

Step 1 of 6

16%

Family Information

Teen's Information:

Name:(Required)

First Last

Age:

Birth Date:

Sex:

Male

Female

Grade:

Referred to us by:

Relationship to referrer:

Please list the days and times your teen is available for counseling sessions between Monday-Friday:

Father's Information:

Name:(Required)

First Last

Age:

Address:

Street Address Unit / Suite Number City State(if applicable) Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Mother's Information:

Name:(Required)

First Last

Age:

Address(if different than Father's address):

Street Address Unit / Suite Number City State(if applicable) Zip Code Country

Phone:(Required)

Email Address:(Required)

Enter Email Confirm Email

Occupation(s):

Education:

Degree(s):

Marriage and Children Information:

Marital Status:

Have you ever been separated?

Yes

If so, when?

From:

Till:

Your ages when married:

Husband:

Wife:

Years married:

How long did you know your spouse before marriage?

Length of steady dating before marriage:

Length of enagagement:

If applicable, please give any information about previous marriages:

Do both biological parents live with the teen coming for counseling?

Yes

Are either of you a stepparent?

Who is the teen's custodian/guardian(s)?

Information about children:

*Please place a “PM” beside any children from a previous marriage*. *Please place an “NL” beside any children not living*. *Please place an “A” beside any adopted children*.

Name:

Birthdate:

Sex:

Education:

Marital Status:

Who currently lives in the same household as the teen? (Please list all persons, including any house guests or extended relatives.)

Does your family regularly read the Bible and pray together?

Yes

Do you have any immediate family members currently living in another country?

Your Teen's Health Information

Approximately how many hours of sleep does he/she get each night?

When does he/she go to sleep at night?

When does he/she get up?

Rate his/her health:

Excellent

Good

Average

Poor

Declining

His/her approximate:

Weight:

Height:

Any weight changes recently?

Does he/she have any chronic medical conditions? Please list and describe:

List all important present and past illnesses, injuries, or handicaps:

Date of last medical examination:

What was the report?

Name and address of his/her physician:

Is he/she presently taking medication?

Yes

Which medication(s)?

Has he/she ever used illegal or abused prescription drugs?

Yes

Unsure

If the counselor believes that it would be helpful to see his/her psychiatric and/or medical reports, would you be willing to sign a release of information form?

Yes

How many times per week does he/she exercise? What type of exercise?

Does he/she have any dietary restrictions?

How would you rate his/her overall eating habits?

Poor

Good

Excellent

Parents' Religious Information:

Have both you and your spouse repented of your sin and placed your faith in Christ? When?

Have both you and your spouse been baptized? When?

Sending Church Information:

Sending church (if applicable):

City/State:

Sending church pastor’s name:

Mission Board/Agency Information:

Name of mission board/agency:

City/State:

Personal Church Information:

Name of church you attend:

City/State:

Name of pastor:

Do you have any other leaders in your church? (List their names and positions):

Denominational preference:

Do both you and your spouse regularly attend church together?

Yes

Number of church services your family attends per month:

Do both parents regularly spend personal time in God’s Word and in prayer?

Yes

Please explain any changes in your spiritual life or your spouse’s spiritual life, if any:

Your Teen's Religious Information

Does your teen believe in God?

Yes

Uncertain

Has your teen repented of his/her sin and placed his/her faith in Christ? When?

Has your teen been baptized? When?

Does your teen attend the same church as you?

Yes

If not,

What church does your teen attend?

City/State:

Is there evidence of faith and a walk with Christ in your teen in the past? In the present? Please explain your answer to the best of your ability:

Explain any recent changes in your teen's spiritual life, if any:

Your Teen's Personal Information

If your teen was raised by anyone other than your parents, please briefly explain:

Was your teen born and raised in the place of your current ministry?

Yes

If not, please list the age of your teen at the time when your family relocated to the place of your current ministry:

Where does your teen attend school?

Does your teen speak any foreign languages? How fluently?

Who are your teen’s closest companions?

What do you see as your teen’s greatest strength? Greatest weakness?

How does your teen handle stress?

Please provide a brief timeline and explanation of any major/impactful events in your teen’s life:

Check off any of the following words that best describe your teen now:

Check off any of the following words which best describe you now:

Introvert

Extrovert

Likeable

Angry

Leader

Quiet

Inflexible

Submissive

Sensitive

Performance-driven

Check off any of the following words which best describe you now:

Often sad

Self-conscious

Excitable

Imaginative

Calm

Serious

Easy going

Bitter

Shy

Fearful

Check off any of the following words which best describe you now:

Active

Ambitious

Self-confident

Persistent

Anxious

Lonely

Hardworking

Impatient

Impulsive

Moody

Your Teen's History Information

Has your teen dealt with severe emotional struggles in his/her past or present?

Yes

Has your teen experienced any traumatic events?

Yes

Uncertain

If yes, what?

Has your teen ever had any therapy or counseling before?

Yes

If yes, please list therapist or counselor and dates:

What was the outcome or result of your teen’s previous therapy/counseling?

At any time, has your teen:

Felt people were watching him/her?

Yes

Had difficulty recognizing faces?

Yes

Been unable to judge distance?

Yes

Had visual hallucinations?

Yes

Had auditory (hearing) hallucinations?

Yes

Been addicted to anything?

Yes

Has your teen ever been arrested?

Yes

If so, please list reason for arrest:

List any fears or worries your teen has about which you are aware:

Five Basic Questions:

Briefly answer the following questions:

What are the main issues your teen is struggling with at this time? When did he/she first begin to experience these problems? Is this a time of crisis?

What has he/she done about it? What have you as parents done about it?

Has anyone in the family experienced similar problems?

What do you hope to be accomplished by bringing your teen to counseling at this time? What are your expectations?

What other information is important to you and your teen’s situation that you would like for us to know?

Our Confidence in Biblical Counseling

What You Can Expect

We will carefully gather all the information needed to understand your unique situation.
You will receive biblical hope and encouragement that your problems can be solved.
You will gain biblical insights into the root causes of your problems.
You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions.

Our Expectations

Confidentiality Policy

The Bible clearly says gossip is wrong. Therefore, SICM will not release information about counselees except in the few situation required by the Bible or by the law. Those situations are:

When the information presented by the counselee may involve criminal or illegal practices or if the counselee poses a threat to himself/herself or others
When there is a clear indication that someone may be physically or sexually abused unless others intervene
When a child or elder over the age of 65 is physically or sexually abused
When a person persistently refuses to biblically repent of and renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22; 24:11; Matthew 18:15-20)

Cost

Consent

I agree to pay my counseling invoices within the time allotted and that I will be billed the cancellation fee should I cancel a session without proper notice.

Counselee's name:

Parent/Guardian's Name

Online Signature

Date

MM slash DD slash YYYY

Please type the characters shown

STAY UPDATED

Name
First Last
Email
Phone
Message
Subscribe
Subscribe to our email list
Please type the characters shown
Captcha