Category Archives: Forms/Assignments

Basic templates for counseling ministry and selected homework assignments.

Overview of the Problem or Conflict You Are Facing

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: ___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________________________________

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

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

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

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

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? ______________

_____________________________________________________________________________________

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

_____________________________________________________________________________________

_____________________________________________________________________________________

 

{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?

_____________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

Advertisements

Counseling Overview

Interested in Biblical Counseling at Open Door Church?
Download this PDF HERE

Open Door Church (ODC) provides church-based, Christ-centered, biblical counseling to individuals, couples, and families to help them know Jesus, or know him more deeply, and to help them find and apply God’s answers for their personal problems and their relational problems. Continue reading

Personal Information Form (PIF)

Personal Information Form (PIF) 

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

 

Name________________________________________  Gender___   Age___   Date_______________

Address _________________________________________________  Email ____________________

(Street/Box)                                       (City)                     (State/Zip)

Daytime telephone ______________ Evening telephone ___________  Referred to us by ___________

Section I — Marital Status/History

Status (underline all that apply): Single  Engaged  Married  Separated   Divorced   Widowed

Your Present Marriage (if applicable):

Spouse’s name _________________________  Age ___  Spouse’s occupation ___________________

Date of marriage _______  Place _____________ Years married ___

If you and your spouse have ever separated, give dates and circumstances: ______________________

__________________________________________________________________________________

Rate your marriage (circle: 0 terrible, 5 excellent):   0   1   2   3   4   5.   What might make it better?

__________________________________________________________________________________

__________________________________________________________________________________

Children from Present Marriage (if applicable):

Name            Son/Daught.    Age      Where Live           Marital Status         Occupation

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Your Previous Marriages (or Relationships that Produced Children) (if applicable):

Name of Spouse/Partner    Dates                Children (Names and Ages)

1.  __________________  _____to_____  ________________________________________________

2.  __________________  _____to_____  ________________________________________________

Has your spouse been previously married? ___   How many times? ___

Children (Names and Ages) ___________________________________________________________

 

 

Section II — Occupational Status/History

Education (last level completed) ________   School/Institute _________________________________

Occupation _____________________  Name of Company ___________________  City/State ______

# Years there ______   Present income (est.) $_________  Work Telephone (____)________________

Does your present work satisfy you? Explain: _____________________________________________

__________________________________________________________________________________

What other job positions have you held in the past? _________________________________________

__________________________________________________________________________________

Section III — Family of Origin History

Parents:  Name                  Age    Where Live    Marital Status       Occupation

Father: ____________________________________________________________________________

Mother: ___________________________________________________________________________

Guardian: _______________  Relation to you: __________  Dates: _________

Brothers/Sisters:  (List in order from oldest to youngest; include yourself in that order):

Name           Bro/Sis/Step  Age   Where Live    Marital  Status    Occupation

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Family “Climate”: Describe your home life during your childhood and teen years: ________________

__________________________________________________________________________________

__________________________________________________________________________________

Indicate any problems you experienced as a child or teen:

Family problems___  School problems___  Emotional/behavior problems___   Legal problems___   Medical problems___  Social problems___ Drug/alcohol problems___  Other:____________________

Psychological Problems: Have you, or any parent or brother or sister, been hospitalized or received professional help for “psychological” problems? Specify person, dates, and problem: ______________

__________________________________________________________________________________

__________________________________________________________________________________

Section IV — Religious Status/History

Past Denominational Background _______________  Present Denom. Preference_________________

Church Presently Attending __________________________________  City & State ______________

Member:  Yes  No        Average # of times per month you attend ___

Pastor ___________________ Telephone ______________  Permission to contact him: Yes  No

Do you believe in God?  Yes  No  Unsure

Do you consider yourself “saved?”   Yes   No   Unsure   Don’t understand the term

How frequently do you pray?  Often  Occasionally  Rarely  Never

How frequently do you read the Bible?  Often  Occasionally  Rarely  Never

What is your view of the Bible? ________________________________________________________

Have you come to the place in your spiritual life where you know for certain that if you were to die today you would go to heaven?  Yes  No  Unsure

Suppose you were to die and stand before God and he were to say to you, “Why should I let you into my heaven?,” what do you think you might say to God? _____________________________________

__________________________________________________________________________________

Why do you desire Christ-centered, biblical counseling? _____________________________________

__________________________________________________________________________________

Explain any recent changes in your religious life:  __________________________________________

__________________________________________________________________________________

Section V — Medical Status/History

Rate your health:  Very Good __  Good __  Average __  Poor __     Recent Problems? __________________

Date of last medical exam: __________  Report ___________________________________________

Your Physician ____________________________________________ City & State_______________

List any prescription medications you take:

Medication                 Treatment for               When began     Daily dosage           Prescribing Physician

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

List over-the-counter medications you currently take (diet pills, laxatives, birth control pills, cold and allergy medicines, aspirin, etc.): __________________________________________________________

__________________________________________________________________________________

List any surgeries that required anesthesia: ______________________________________________

__________________________________________________________________________________

Average daily caffeine consumption?  (coffee, tea, chocolate, stimulants, caffeinated soft drinks, etc.)  __________________________________________________________________________________

How often do you drink alcoholic beverages?   Often  Occasionally  Rarely  Never

How often do you struggle with the temptation to use illegal drugs?   Often  Occasionally  Rarely  Never

Average # of hours of sleep each night? ___  Is it restful? ____________________________________

Describe any recent changes in your sleep patterns: _________________________________________

__________________________________________________________________________________

Have you had any of the following physical problems?  Please check.

Heart problems ___                            Hypoglycemia ____                           Menstrual irregularities ___

Liver problems ___                             Lung Problems ____                           Hallucinations ____

Kidney Problems ___                         Allergies ______                                  Change in sexual drive ____

Head injury/concussion ___             Cancer ___                                           Problems walking ___

Stroke ____                                          Incoordination ___                             Unusual hair loss ___

Seizures ____                                       Anorexia or Bulimia  ___                  Rashes ___

Brain Tumor ____                              Visual Problems ____                         Memory Problems ____

Multiple Sclerosis ___                         Sensory distortions ____                    Episodic disorientation ___

Parkinson’s Disease ___                    Weakness ____                                   Personality change ____

Blackouts ____                                   Fatigue ____                                        Deja Vu ___

Amnesia ____                                      Heat/cold sensitivity ___                   Changes in consciousness ___

Tremors ____                                       Bowel/bladder problems ___            Headaches ____

Thyroid dysfunction ___                   Nausea or vomiting ___                     Dizziness ____

Diabetes ___                                        Recent weight change ____              Stiff neck ___

High Blood Pressure ___                    Impotence ___                                    Physical changes ___

Constant Hunger  ___                        Food cravings ___                               Fever ___

Pneumonia ___                                   Speech Problems ___                         OTHER? _________________________________

Have you or others noticed any changes in your personality (anger, mood swings, withdrawal), your thinking and memory, or your work habits? _______________________________________________

__________________________________________________________________________________

Section VI – Legal Actions (if applicable, for example, in conflict or separation/divorce cases)

If you have talked with an attorney about your problem, or intend to, please provide the following info:

Attorney                                                        Firm                                                                         

Address                                                                                             Phone                                  

     Date and purpose _______________________________________________________________

Has a legal action been filed or is one likely to be filed in this situation?  No  Yes  (If yes, give dates and describe action below.)

Other information that might be helpful for us to know about you (attach separate sheet if needed)

Biblical Counseling Agreement

Biblical Counseling Agreement

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

 

Thank you for your interest in church-based, Christ-centered, biblical counseling and for giving us an opportunity to serve you. We look forward to helping you find God’s help and hope for the personal or relational problems you are facing. The following information will help you further understand our ministry and will serve as an agreement between us.

I.  General Comments:

Before reading this agreement form, please read our other document, “Interested in Biblical Counseling?” to understand what we mean by church-based, Christ-centered, biblical counseling.

Your counselor is a member of a local church and is ministering under the authority and direction of the church’s pastors. He or she is a church-trained biblical counselor, not a licensed psychologist, therapist, or psychiatrist, and offers Christ-centered, biblically-based counseling, not psychological counseling. If you have significant legal, financial, medical, or other technical questions, you should seek advice from an independent professional. Your counselor will seek to help you apply God’s Word to your life, based on your counselor’s understanding of God’s Word.

Your counselor may have one or more church members or leaders present in the sessions to assist him or her, observe him or her for ministry training purposes, or to serve you as mentors. These individuals will observe the same standards of care and confidentiality as your counselor.

You or your counselor may choose to discontinue counseling at any time, without explanation.

 

II.  Making the Process Most Effective:

To increase the effectiveness of the ministry process, your counselor asks the following of you:

1. Be committed to biblical counseling as described on this sheet and any other accompanying materials your counselor gives. Come to each session with a humble spirit, seeking to learn how God wants you to handle your problems based on his Word.

2. Attend each scheduled session. Allow 50-60 minutes for a session. If an emergency arises and you cannot attend a session, please contact your counselor as soon as possible at (919) 675-1594 and leave a detailed message for your counselor including your name and phone number for them to get back to you. Your counselor does not usually do telephone counseling and cannot reply to frequent phone calls, email, or postal correspondence.

3. Be as open and honest as you can. At the same time, your counselor realizes that talking about your problems may be very difficult for you and that your trust in him or her may take time to develop.

4. Be patient—your problems did not develop in a day. It may take your counselor several sessions to obtain a good understanding of your situation. It is vital for him or her to carefully listen and gather needed information and to build understanding and trust with you.

5. Complete any growth assignments given, and review and pray over the matters discussed during previous sessions. Your counselor will give you assignments that fit our counseling aims and will help you make progress between sessions. Failure to complete them may indicate lack of commitment to the process, and may result in discontinuation of the process.

6. Attend one of our three Sunday morning worship services and one of our adult Bible fellowship classes each week. Your counselor can discuss these options with you. Regular participation in a Christ-centered, biblical church like ours provides you with vital complements to our counseling: God-centered worship, solid Bible teaching with practical life application, pastoral care, and meaningful friendships with other people needing—and learning—God’s grace together.

III.  Confidentiality and Legal Concerns:

Confidentiality is an important aspect of the counseling, and your counselor will carefully guard the information you entrust to him or her. We desire as much as possible to protect your privacy.

At the same time, you must realize that this confidentiality is only within the limits of biblical and civil law. Your counselor cannot guarantee absolute confidentiality in every situation. For example, to ensure that you are receiving consistent counsel and support, your counselor might need to discuss your situation with appropriate leaders of your local church, or, in some cases, with your attorney, if you have one. Furthermore, he or she might need to divulge information to appropriate civil authorities if there is indication that you or someone else might otherwise be harmed. In counseling minor children, your counselor might need to divulge information to parents or legal guardians.

Your counselor also asks you to agree not to discuss our communications with people who do not have a necessary interest in the counseling or conciliation process. In addition, where your situation might involve legal issues, you must agree to treat all dealings with him or her in regard to this counseling as settlement negotiations, which means they will be inadmissible in a court of law or for legal discovery. Furthermore, you must agree that you will not try to force your counselor to divulge any information acquired during the counseling process or to testify in any legal proceeding related to the process.

In the unlikely event of a conflict between you and your counselor, all parties must seek to resolve it in a biblical manner, through discussion, and, if necessary, through mediation and arbitration, according to the Rules of Procedure of the Institute for Christian Conciliation, available at Peacemaker Ministries’ website (www.peacemaker.net). For further information about confidentiality, see the Guidelines for Christian Conciliation at the same website.

*  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *

Agreement by Counselee(s): If you have any questions about the above matters, please talk with your counselor or our church leaders. If you agree to these terms, please sign below and return this sheet to your counselor before or at the beginning of your first meeting.

 

I have read and understand the above guidelines and find them acceptable.

 

Name _________________________  Signed ___________________________  Date ____________

Name _________________________  Signed ___________________________  Date ____________

Name _________________________  Signed ___________________________  Date ____________

Agreement by Others Present in the Session:

 

I have read and understand the above guidelines and I will observe them in the counseling process.

 

Name _________________________  Signed ___________________________  Date ____________

Name _________________________  Signed ___________________________  Date ____________

Name _________________________  Signed ___________________________  Date ____________

Thank you for giving us the opportunity to serve Jesus by helping you find and apply his answers to your problems. May God encourage, bless, and empower you in these coming days!