PIF Adult 5

Personal Information

Check off any of the following words which best describe you now:
History Information
Have you dealt with severe emotional struggles in the past or present?
Have you experienced any traumatic events?
Have you ever had any therapy or counseling before?
At any time, have you:
Felt people were watching you?
Had difficulty recognizing faces?
Been unable to judge distance?
Had visual hallucinations?
Had auditory (hearing) hallucinations?
Been addicted to anything?
Have you ever been arrested?
Five Basic Questions:

Briefly answer the following questions:

Distinctives and Consent to Counsel
Our Confidence in Biblical Counseling

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, we 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.


It costs Selah International $130 per session to provide this level of personalized counseling and solutions. 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 info@selahinternational.org. 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.

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.


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.


I 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.


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.