COUNSELING INTAKE FORM 

Welcome to the counseling ministry at Harvest Bible Chapel North Indy. We know it’s not easy to ask for help and we are so grateful that you have invited us into your life at this time. It is our prayer that God will bless you and use our time together to build more hope and direction into your life. The next step in the counseling process is to complete the following intake form. This form is designed to (1) help us to get to know you in a comprehensive and holistic manner (2) help you organize your thoughts about your counseling objectives and (3) help establish the guidelines of commitment and confidentiality between you and your counselor. Rest assured that this form will only be given to your assigned counselor and all information will remain confidential. Please allow approximately 30-45 minutes to complete these forms. Please read and answer this form carefully. Simply put “NA” if the answer is not applicable to you.

NAME *
NAME
Birthdate *
Birthdate
GENDER *
Phone *
Phone
Address *
Address
Family Information
Employment Information
Spiritual Information
Health Information
RATE YOUR HEALTH *
Personality Information
CHECK ANY OF THE FOLLOWING WORDS WHICH BEST DESCRIBE YOU
Summary of Current Situation
CONSENT TO BIBLICAL COUNSELING
Our Goal: Our goal in providing biblical counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to enjoy fully His love for you and His plans for your life. Biblical Basis: We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of secular psychology or psychiatry. None of our counselors are trained or licensed as psychotherapists or mental health professionals, nor should they be expected to follow the methods of such specialists. Confidentiality: Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. There are four situations when it may be necessary for us to share certain information with others: (1)When the counselor is uncertain of how to address a particular problem and needs to seek advice from another pastor / elder in this church; (2) when a counselee attends another church and it is necessary to talk with his or her pastor or elders; (3) when there is a clear indication that someone may be harmed unless we otherwise intervene; or (4) when a person persistently refuses to renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (see Proverbs 15:22; 24:11; Matthew 18:15-20). Please be assured we strongly prefer not to disclose personal information to others, and will make every effort to help you find ways to resolve a problem as privately as possible. Resolution of Conflicts: On rare occasions a conflict may arise between counselor and counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner, we require all of our counselees to agree that any dispute that arises with the counselor or with this church as a result of counseling will be settled with mediation within the church according to the principles of scripture and the authority of this local church. If these guidelines are acceptable to you, please sign below.
TYPE YOUR FIRST AND LAST NAME IN THE FIELD BELOW.
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above confidentiality statement. *
TODAY'S DATE *
TODAY'S DATE
COMMIT TO BIBLICAL COUNSELING
As your Biblical Counselor we commit to the following: Praying for and with you in our meetings. Hearing your story and understanding your situation to the best of our ability before giving counsel. Opening God’s Word with you in relevant and persuasive ways. Speaking the truth in love as we address your problems. Giving homework that is helpful in your life and situation. As the Counselee we ask you to commit to the following: Meet weekly for 75-90 minutes each time. (Note: Frequency may change as counseling progresses) Arrive to appointments on time and remain consistent in your counseling attendance. Attend Sunday morning worship at Harvest throughout the counseling process. Allow others to be involved in your life while counseling including an advocate to meet with us and/or participation in a small group as recommended by your counselor. Spend time in prayer and Bible reading throughout each week. Complete all assigned homework and come prepared to each session.
Sign below if you are willing to commit to the above expectations
TYPE YOUR FIRST AND LAST NAME IN THE FIELD BELOW