VICTORY PLACE BIBLICAL COUNSELING CENTER “But thanks be to God! He gives us the VICTORY through our Lord Jesus Christ.” 1 Cor. 15:57 Step 1 of 9 11% 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. (II Peter 1:3 and Romans 15:4). Therefore, our counseling is based only on scriptural principles rather than those of secular psychology or psychiatry. Although some of the pastoral or lay counselors of this church may be licensed in other fields, such as medicine or psychology, they will not practice as professionals but as Biblical counselors. Not Professional Advice— Some of our counselors work in professional fields outside this ministry. When serving as counselors within this ministry however, they do not provide the same kind of professional advice and services that they are hired in their profession capacities. Therefore, if you have significant legal, financial, medical or other technical questions, you should seek advice from another independent professional. Our pastor and lay counselors will be happy to cooperate with such advisors and help you to consider their counsel in the light of relevant scriptural principle. Confidentiality— Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. However, because we are continually training others to be effective counselors we ask that you agree to allow counselors in training to be present during your sessions. There are four other situations when it may be necessary for us to share certain information with others (1) When a counselor is uncertain how to address a particular problem and needs to seek advice from another member of the pastoral leadership 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 that our counselors strongly prefer not to disclose personal information to others, and they make every effort to help you find ways to resolve a problem as privately as possible. Childcare— Unfortunately, at this time we cannot provide childcare while you attend your counseling session. If you have children who are not involved in the counseling session itself, please do not bring them with you to your session. 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. Fees— Our counseling is free of charge as a service to our community. However, our cancellation policy requires that you cancel a scheduled appointment no less than 24 hours prior to your appointment time (email: datkinson@sjbcfamily.com call: 682-400-3474). Failure to cancel an appointment within this timeframe may result in forfeiting your allotted time slot. Since our ministry regularly has a waiting list, it could be some time before your preferred time slot becomes available. Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His church. If you have any questions about these guidelines, please contact our office at 972-264-1483. If these guidelines are acceptable to you, please sign below. Printed Name:(Required)Signed:Max. file size: 20 MB. Create and Upload Signature https://www.signwell.com/online-signature/draw/Date(Required) MM slash DD slash YYYY PERSONAL DATA FORM Welcome to Victory Place Biblical Counseling Center. In order to serve you better, we request that you take a few moments to fill out the following information. Today’s date:(Required) MM slash DD slash YYYY Full Name(Required) First Address(Required) Street Address City State / Province / Region ZIP / Postal Code Home Phone(Required)Work PhoneCellEmail(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required)Please enter a number from 1 to 100.Gender(Required) Male Female Place of Employment(Required)Occupation/Position(Required)May we call you and leave a message for you at your home?(Required) Yes No May we call you and leave a message for you at work?(Required) Yes No May we write you at your home?(Required) Yes No May we email you?(Required) Yes No Who referred you for counseling?(Required)Times you are available for counseling:(Required) Mornings Afternoons Evenings Days you are available for counseling:(Required) TUE WED THUR SAT Are you seeking an appointment in person, virtually, or either? (Select which applies)(Required) In person Virtually Either MARITAL STATUS: Current Marital Status:(Required) Never Married Married Divorced Separated Widowed N/A Name of Spouse:Date of Marriage: MM slash DD slash YYYY If married, are you or have you ever been separated? Yes No If yes, list date of separation?(Required) MM slash DD slash YYYY Have either you or your spouse ever filed for divorce? Yes No If yes, date divorce was filed:(Required) MM slash DD slash YYYY How long did you know your spouse before marriage?Did you attend pre-marital counseling? Yes No If yes, list where you received your pre-marital counseling:Self: Name of Previous Spouse Add RemoveDate of Marriage Add RemoveDate of Divorce/Death Add RemoveSpouse:Name of Previous Spouse Add RemoveDate of Marriage Add RemoveDate of Divorce/Death Add RemoveYour education level: GED High School Diploma College Degree Graduate Degree N/A Spouse’s education level GED High School Diploma College Degree Graduate Degree N/A List your children: Name Add RemoveGender Add RemoveAge Add RemoveFather/Mother First Name Add Remove RELIGIOUS BACKGROUND: Are you a believer in Jesus Christ as your Lord and Savior?(Required) Yes No Unsure If yes, describe circumstances of your conversion:N/AIf yes, what are you doing on a regular basis to grow in your relationship with the Lord?N/AAre you currently attending a church?(Required) Yes No If yes, what is the name of the church and the year you joined:N/ADescribe the ministries in which you are involved:N/AIn what areas would you like to grow in your walk with the Lord?N/AHow often do you attend church per month?(Required)02345678910+Did you attend a church as a child?(Required) Yes No If yes, what church did you attend?Have you been baptized?(Required) Yes No HEALTH INFORMATION: Rate your physical health:(Required) Very Good Good Average Declining Weight changes recently (+ / -):List of all present or past illnesses: Add Removehandicaps: Add Removeinjuries: Add Removehospitalizations: Add RemoveDate of last medical examination: MM slash DD slash YYYY List all exams in the last year:N/AList your physician (name, contact information):N/AList any medications and/or supplements that you are presently taking and how long you have been taking them:N/AHave you used drugs for other than medical purposes?(Required) Yes No If yes, list what hat drugs and when:Have you ever had a severe emotional upset?(Required) Yes No If yes, explain:Have you ever attempted suicide?(Required) Yes No If yes, briefly explain: PREVIOUS COUNSELING: Have you been in counseling before(Required) Yes No If yes, list each therapist/counselor(s)?N/AList each problem?N/AWhat was the dates?N/AWhat was the results?N/APhysical symptoms you are currently experiencing? (check all that apply)(Required) PMS Headaches Sinus infections Eating disorder Throat problems Hypoglycemia Stomach pain Sleeping problems Heavy periods Backaches Breathing difficulties Other: Select AllWhat emotional symptoms are you currently experiencing? (check all that apply)(Required) Frustration Bitterness Guilt Irritation Depression Fear Outburst of anger Emotional pain Indecision Resentment Self-pity Other: Select AllIs there anything else you would like us to know about you? FAMILY AND CHILDHOOD INFORMATION: If you were reared by anyone other than your own parents, briefly explain:N/AHow many older brothers do you have?(Required)older sisters do you have?(Required)How many younger brothers do you have?(Required)younger sisters do you have?(Required)List the people that you hate or are extremely angry with, and the reasons:N/AWere you ever sexually abused by anyone? Yes No If yes, what was or is the relationship of the person who abused you?If yes, how old were you at the time?Please enter a number from 1 to 100.If yes, was the person who abused you ever prosecuted? PERSONAL BEHAVORIAL HABITS: How much television do you watch each day in hours?(Required)List books, movies, and television programs you have viewed in the last 6 months:N/AList the music you have listened to in the last 6 months?N/ADo you drink coffee or any other caffeinated drinks?(Required) Yes No List how many caffeinated drinks you consume per dayDo you smoke or chew tobacco?(Required) Yes No List what type and how much per day? COUNSELING EXPECTATIONS: Is there a crisis in your life right now? If yes, describe conditions and effects:(Required)What is the main problem that brings you to counseling?(Required)How troubled are you by this?(Required) Constantly Often Somewhat Not very much What have you done about it so far?(Required)What expectations do you have regarding this counseling?(Required)What reservations or concerns do you have about seeking counseling?(Required)