Adult 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 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. - Grace Baptist ChurchGeneral InformationName:(Required) First Last Phone:(Required)Address:(Required) Street Address Unit / Suite Number City State Zip Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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:Please Choose OneElementaryHigh SchoolGEDCollegeGraduateOther Training (Please list type and years):Marital Status:Please Choose OneSingleEngagedMarriedSeparatedDivorcedRemarriedWidowHow many siblings do you have?Older brothersOlder sistersYounger brothersYounger sisters Marriage and Family InformationName of Spouse: First Last Spouse's Phone:Spouse's Age: Spouse's Birth Date: Spouse's Occupation(s): Spouse's Education:Please Choose OneElementaryHigh SchoolGEDCollegeGraduateDegree(s): Spouse's Other Training (Please list type and years):Does your spouse know that you are coming for counseling? Yes No Is your spouse willing to come for counseling? Yes No Uncertain Have you ever been separated? Yes No If so, when? Your ages when married:Husband:Wife:Years married: Add RemoveHow 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: Add RemoveDoes your family regularly read the Bible and pray together? Yes No Health InformationApproximately 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: Add RemoveAny 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 No Which medication(s)? Have you ever used illegal or abused prescription drugs? Yes No 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 No 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 InformationDo you believe in God? Yes No 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 No 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 No How would you describe what God is like?Number of days you read the Bible in any given week:01234567How 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:01234567891010+ Personal InformationIf 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: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 InformationHave you dealt with severe emotional struggles in the past or present? Yes No Have you experienced any traumatic events? Yes No Uncertain If yes, what? Have you ever had any therapy or counseling before? Yes No 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 No Had difficulty recognizing faces? Yes No Been unable to judge distance? Yes No Had visual hallucinations? Yes No Had auditory (hearing) hallucinations? Yes No Been addicted to anything? Yes No Have you ever been arrested? Yes No 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 CounselOur Confidence in Biblical Counseling At Grace Baptist Church, 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, GBC 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. Consent I agreeI 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 agreeI 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 agreeI understand GBC counselors do not use psychological models or insights to help me with explaining or solving my problems. I understand that GBC counselors are biblically trained and certified to counsel. I understand GBC seeks to use the Scriptures to interpret, instruct, and inspire solutions. Consent I agreeI understand that GBC 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 GBC. I understand that my counselor will clearly communicate with me prior to initiating contact with my pastor and/or appropriate spiritual authority.Please inform GBC of specific communication instructions if security concerns exist for transmission of sensitive information online. While GBC 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
