UNITE Counseling PDI – Unity Baptist Church

UNITE Counseling Form

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GENERAL PERSONAL INFORMATION

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age(Required)

Sex(Required)

Occupation(Required)

If unemployed, please list previous employments

Describe What You Do in your Occupation and Significant Information about Your Workplace:(Required)

Please List Your Education Experiences, Degrees, Certifications, Etc.(Required)

GENERAL FAMILY INFORMATION

Relationship Status(Required)

Describe this Relationship in One or Two Words:(Required)

How Long Have You Been Married? (if applicable)

How Long Have You Known Your Spouse? (if applicable)

Check ALL That Apply:

My Spouse is Aware of My Counseling Need

My Spouse is in Favor of Me Coming to Counseling

My Spouse is Willing to Join Me in Counseling

Check ALL That Apply:

I Have Been Divorced

I Have Been Separated From My Spouse

I Have Filed for Divorce

List Children's Names, Ages, and Occupations (if applicable):

Name

Age

Occupation

Relationship Status

Please Explain Previous Relationships, Length of Relationships, and/or Children Born from the Relationships:(Required)

Please List the Names and Ages of your Parents:

(If deceased, please indicate the date that they died)

Please Describe the Relationship with Your Parents:

(If deceased, indicate what kind of relationship you had with them)

Please List the Names and Ages of Your Siblings (if applicable):

Please Describe the Relationship with Your Siblings (if applicable):

GENERAL HEALTH INFORMATION

Describe Your Overall Health:(Required)

Date of Last Medical Exam:

Primary Care Physician/Office:

General Results of Last Medical Exam:

Please List all Injuries, Handicaps, Chronic/Current Illnesses:

Describe Your Quantity and Quality of Sleep Most Nights:

Select All That Apply:

I'm Currently Taking Prescribed Medication

I'm Currently Taking Unprescribed Medication

I Have Used Drugs/Substances for Non-Medical Purposes

If You Selected One of the Options Above, Please List the Name, Dosage, and Frequency of Each Below:

Would you Allow your Counselor to Sign a Release of Medical Information if Requested by a Psychiatric or Medical Professional?

Yes

Please Indicate any Recent Change in Physical, Emotional or Psychological Health:

GENERAL SPIRITUAL INFORMATION

Select All That Apply:(Required)

How Often Do You Attend a Church Service(Required)

How Often Do You Pray or Read the Bible?(Required)

If applicable, does your spouse or children attend church with you?

Indicate any Recent Changes in your Spiritual Condition:

OTHER INFORMATION

Have You Ever Been Arrested? (If yes, briefly explain)

Time Spent on Social Media PER DAY:

0-1 Hours

2-5 Hours

5-10 Hours

10+ Hours

Please Indicate Which Social Media You Use and What Time of Day that You Engage with Each One:

If You Have had Therapy or Counseling Before, Please Describe "Why", the Type of Therapy/Counseling, and What the Results Were:

SPECIFIC ISSUES / PROBLEMS

What Brings You Here for Counseling? How Would Your Describe the Main Problem(s)?

What Have You Done to Address or Solve the Problem(s), so far?

What Do You Expect From This Counseling Experience?

What Other Information Should We Know About You or the Problem(s)?

TERMS, CONDITIONS AND CONFIDENTIALITY AGREEMENT

Terms and Conditions(Required)

On the date that this form is completed and confirmed to be read and understood, it is agreed that an approved “Counselor” of Unity Baptist Church of Gillespie, IL, will provide biblical counseling services to a “Counselee," as designated by this form, on the following terms and conditions:

Biblical Counseling: This is a ministry of the Gospel of Jesus Christ and is part of Counselor’s practice of religion. Counselee has indicated that Counselee is a Christian and/or is voluntarily seeking religious guidance (biblical counseling) from Counselor, as a part of Counselee’s practice or pursuit of religion. Counselee’s testimony or evangelistic pre-counseling will establish that the counselee is a candidate for the end goal of biblical counseling which is to help Christians become more like Jesus Christ in attitude, thought, and action. Counselor’s goals, in providing counseling are to help Counselee to know the God of the Bible more fully and vitally and to live life in a God-honoring way. This includes, but is not limited to, providing biblical
counsel to assist in: meeting the challenges of life, increasing in true worship, applying the gospel and God’s sufficiency daily, shedding the sin that so easily entangles, learning to develop, cultivate, and live in relationships that please God, giving thanks to God in all circumstances, living in a community of other believers through participation in a local church, and learning to rely on the Holy Spirit for power and direction through prayer and Bible study. Although the biblical advice Counselor provides is intended to be practical, it is entirely Counselee’s decision how to (and whether to) implement that advice. Counselor wants to help Counselee love God and love others through this process.

Biblical Basis: Counselor believes that the Bible provides sufficient guidance and instruction for faith and life. Therefore, counseling is based on biblical principles rather than those of secular psychology or psychiatry. Counselor is not licensed or certified as a psychotherapist, psychologist, psychiatrist, mental health professional, marriage and family therapist, or social worker, and is not acting in such capacities. If Counselee is unwilling to use the Bible as the final authority in counseling or is unwilling to do the homework assigned, Counselee should not proceed with this counseling.

Professional Advice: Counselor is not providing legal, tax, financial, medical, or other technical or professional advice and Counselor undertakes no duty to recognize or opine when such advice is actually needed, and the parties further agree that no fiduciary or professional client relationship is being created between Counselor and Counselee as a result of this relationship. While the counselee may provide renumeration for the ministerial services provided pursuant to this agreement, such renumeration does not change this relationship from a religious to a "professional" or "fiduciary" relationship.

Confidentiality: Confidentiality is conditional. Although confidentiality is often one aspect of the counseling process and Counselor intends to guard the information received from Counselee, there are a number of situations when it may be necessary or prudent (as determined in Counselor’s sole discretion) for Counselor to share information with others. Counselee agrees that Counselor may share information in at least the following circumstances:
• When Counselor is uncertain how to address a problem and needs to seek the advice from a pastor, supervising counselor, or educator. (Proverbs 11:14; 24:6).
• When there is concern that someone is being or may be harmed unless other persons or protective services intervene (Romans 13:1-7).
• When Counselee expresses clear and specific suicidal intent, Counselor may take reasonable measures for the safety of Counselee. Reasonable measures may include notifying police if the Counselee will not cooperate to involve him or herself in a watch care program or facility.
• If Counselor has reasonable cause to believe that an adult is in need of protective services, Counselor may take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of a threat or intent and/or informing the appropriate protective and/or law enforcement agencies.
• If there is a claim of, the observance of, or clear reasonable cause to suspect the physical or sexual abuse of a child with whom Counselor comes into contact or who is associated with someone to whom Counselor is in contact with, reasonable measures may be taken to ensure the child’s protection and/or to fulfill the legal mandate to report such harm to the appropriate governmental protection agencies.
• When Counselor becomes aware of any other criminal activity Counselee is engaged in and Counselee refuses to bring to the appropriate biblical and/or legal authorities.
• When counseling someone who is under familial authority (e.g. wife to husband, child to parent) and if deemed safe by Counselor, Counselor may encourage Counselee to inform Counselee’s familial authority of critical issues and/or Counselor may inform the familial authority (Ephesians 5:22-6:4).
• When a person refuses to renounce a particular sin and/or refuses to confess it to those impacted, Counselor may in Counselor’s discretion, seek the assistance of a trusted member or leader of any involved church to encourage repentance and/or reconciliation (Proverbs 15:22, 24:11; Matthew 18:15-20).
• When Counselor deems it appropriate or necessary to discuss information with a training observer or an assisting advocate who is involved or observing counseling.
• When Counselee makes a complaint against Counselor, an ACBC counselor, or a biblical counseling center or other related organization, handling it biblically may involve sharing information with an assisting local Church Shepherd and/or the appropriate person(s) within the ACBC organization for complaint resolution purposes.
Please be assured that our counselors strongly prefer not to disclose your personal information to others (if not needed), and they will make every effort to help you find ways to resolve a problem as privately as possible.

Liability: It is intended that the Holy Scriptures (the Bible) shall be the authority governing the counseling process, and that God’s glory is the ultimate goal. However, failure of Counselor to interpret or apply the Bible in any particular way shall not subject the Counselor to liability or give rise to complaint by anyone. There shall be no legal or other liability that attaches to Counselor or any related institution or person for any advice, methods, conduct, or any act or omission related in any way to the service that is provided, and Counselee acknowledges that Counselee is voluntarily seeking this counsel (free from coercion, duress, or pressure) with a full understanding of the nature, purpose, and effect of this agreement.

Termination: At any time and for any reason, Counselor or Counselee may terminate counseling. However, termination will not preclude Counselor from making the disclosures set forth above if deemed appropriate by Counselor, or if compelled by other legal means. Counselor is not required to keep records, but if records are made, Counselor may destroy any such records without incurring liability.

Resolution of Conflicts: On rare occasions, a conflict may develop between a Counselor and a Counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner (the Bible prohibits lawsuits in court among believers; 1 Cor. 6:1-8), the parties agree that if a conflict arises, the conflict will be resolved according to the ACBC dispute resolution proceedings, which are then operative. That conflict resolution policy may be found at https://biblicalcounseling.com/acbc-member-complaint-case-policy/.

BY SIGNING THIS DOCUMENT, YOU ARE IRREVOCABLY WAIVING ANY RIGHT THAT YOU MIGHT HAVE TO A TRIAL BY JURY OR JUDGE IN A JUDICIAL PROCEEDING.

If any provision of this agreement shall be held invalid, illegal, or unenforceable, only that provision shall be stricken, and the remainder of the agreement shall be in no way affected.
By selecting the "I confirm" statement below, the parties agree to the terms and conditions set forth in this document and acknowledge that Counselor would not enter into this counseling relationship without each term set forth above.

If all of the above is understood and agreed, please select the confirmation below:

I confirm that I have read and understood the terms outlined above.

SIGNATURE

Please Type Your Full Name as a Signature

Today's Month/Day/Year of This Signature

Unity Baptist Church