Overview of the Problem or Conflict You Are Facing

Robert D. Jones, D. Theol., D.Min.

Name __________________   Telephone # _____________  Email __________________ Date _______

This brief overview helps you clarify your understanding of your problems or conflicts, and your desires and expectations for meeting with us. It also helps us gain an initial understanding of you and your situation. Don’t be overly thorough or precise; you will have time during our discussion to explain and expand on what you have written. Your counselor or conciliator will treat your answers as confidential (per our Agreement form); you need not share them with your spouse or others.

1.  Briefly state in your own words the problem(s) or conflict(s) you are facing: ___________________________________________________________________________________________________________________________________

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2.  For how long have you been facing these problems? __________________________________________________________________________________________________________________________________

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3.  What have you done so far about these problems?

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4.  How might you like your counselor to try to help you?

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5.  What issues or questions do you want to have resolved or answered?

6.  As you see yourself, what kind of person are you? How might you describe yourself? ______________

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7.  List any other information about you or the problems that might be helpful for us to know: _________

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{Side 2 for marriage, family, or relationship counseling, or for conflict dispute resolution}

8.  For marriage, family, or relationship counseling (or conflict dispute resolution) only: In what specific ways do you think God might want you to change (be honest), and might want your spouse and/or your other family members to change (be tentative)?

Person                                     Possible Changes Needed:

Þ  You                                    1) ___________________________________________________________________

2) ___________________________________________________________________

3) ___________________________________________________________________

4) ___________________________________________________________________

Þ  ________               1) ___________________________________________________________________

2) ___________________________________________________________________

Þ  ________               1) ___________________________________________________________________

2)  __________________________________________________________________

Þ  ________               1) ___________________________________________________________________

2) ___________________________________________________________________

Þ  ________               1) ___________________________________________________________________

2) ___________________________________________________________________

9.  For dispute resolution concerns:  What do you want from the other party? If there are legal matters involved (such as marital separation or divorce), what claim or remedy do you seek?

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