PERSONAL INFORMATION FORMS

Adult/Child

Adult

Step 1 of 5

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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, the more detailed and transparent you are, the more effective and helpful our counselors can be! - 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 days and times you are available for counseling sessions between Monday-Friday:

Occupation(s):

Education:

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

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

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:

Religious background of spouse:

Denominational preference:

Church attended in childhood:

City/State:

Name of church 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?

Have you spoken with anyone in your church leadership regarding the topic(s) that bring you to counseling here? If so, please list their name(s) and position(s) in your church:

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 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 that best describe you now:

Introvert

Extrovert

Likeable

Angry

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:

Been addicted to anything?

Yes

What addictions have you had?

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 fill out the following scholarship application form if you believe you are in need of a scholarship. We seek to preserve these scholarships for those who need them most, so please speak openly and honestly about your needs.

Scholarship Application

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 SICM provides counsel in accordance with the authority of the local church. I understand that my pastor and/or appropriate spiritual authority will be appropriately informed of my counseling relationship with SICM. I understand that my counselor will clearly communicate with me prior to initiating contact with my pastor and/or appropriate spiritual authority.

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.

Consent

I agree

I understand that I will only be eligible to receive a scholarship if I take the necessary steps to complete the application process mentioned above.

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