Name
*
First Name
Last Name
Phone
(###)
###
####
Email
Occupation
Date of Birth
MM
DD
YYYY
Sex
Relationship Status
Do you attend church regularly?
Yes
No
Sometimes
Major Holidays
What church do you attend?
Have you previously sought counseling from any source for any reason?
If so, for what reason and do you feel it was successful? Why or why not?
What was the reason for the termination of the counseling?
Please briefly describe the reason you are here for counseling:
Do you have specific or general goals that you wish to achieve through pastoral counseling?
Please Note: I AM NOT Secular or a STATE LICENSED Clinical Psychologist, psychotherapist, Social Worker, Licensed Professional Counselor, or Psychiatrist. I simply offer you counseling based on a Christian Worldview using the Word of God, and in prayer led by the Holy Spirit.
Goal: My goal in providing Christian counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and enable you to enjoy fully His love for you and His plans for your life. Biblical Basis: I AM NOT a secular or state licensed Clinical Psychologist, psychotherapist, Social Worker, Licensed Professional Counselor, or Psychiatrist. I am an ordained and endorsed minister of the Gospel of Jesus Christ and an appointed Chaplain for the Virginia Defense Force, who provides counseling based on a Christian Worldview using the Word of God and prayer led by the Holy Spirit. I believe that the Bible and Christian resources provide thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles and a Christian World View rather than those of secular psychology or psychiatry. Not Professional Therapy or Psychology: While the goal of counseling is to help in your relationships and other areas, I am not a professional therapist or psychologist. Therefore, if you have significant legal, financial, medical, or other technical questions, you should seek advice from an independent professional providing services within those fields. Confidentiality: Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. Under the Commonwealth of Virginia code § 19.2-271.3, any communication provided to me in the usual course of practice, including pastoral counseling, shall not be required to be provided as testimony in any criminal or civil matter. There are five situations, however, when it may be necessary for us to share certain, general or specific information with others: (1) when a counselor is uncertain how to address a particular problem and needs to seek advice from another pastor, counselor or elder in this church; (2) when a counselee poses a “clear and imminent danger” either to self or someone else; (3) or when a person discloses child, spouse, elderly abuse or disabled person); (4) If the counselee is or becomes a “vulnerable adult; (5) when the counselee is a minor, the parents are entitled to know the condition, and progress of counseling. Proof of (legal guardianship and custody) consent required. (6) You require referral to alternate/additional services and communication regarding status and state of counseling with me needs to occur between myself and the referred provider. 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. 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, conflicts that cannot be resolved will be referred to another pastor. Agreement: By signing this consent, you agree that you will not attempt to subpoena or require me as a counselor to appear in any legal proceeding related to any matters discussed during counseling; nor will you attempt to subpoena any notes or records related to this counseling. Further, you are agreeing that you understand that all counseling provided to you is from a biblical worldview and, should I determine that you require any therapeutic, behavioral, or psychological counseling or biblical counseling which exceeds the tenents, doctrine, or authority of my endorsing body and faith. Lastly, you agree that I may refer you to additional or alternate services and discuss previous findings with those persons on an as needed basis. Having clarified the principles and policies of the counseling ministry, I 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 body. If you have any questions about these guidelines, please talk with me as your pastoral counselor. If these guidelines are acceptable to you, please sign below.
Consent
I have read all of the above and I agree
I do not agree
Name
First Name
Last Name
Date
MM
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