Application for Biblical Counselling

Please take the next 30 minutes or so to complete this inventory.

By completing this, it gives your counselor good preliminary information in order to get a “running start” in the early sessions.

We offer this counseling with the fundamental belief that the Bible is completely sufficient to meet all of life’s most difficult circumstances. Thus, our counseling keeps the Bible at the forefront of everything we teach and counsel.

Although our counseling is free, we have four primary requirements for counseling. If you can agree to these, please complete the form below.

1. You must be teachable

2. You must be honest

3. You must do your homework

4. If able, you must attend Neighborhood Church Ocala during the time you are being counseled (it is not a requirement to give or serve)

If you have any questions you can text us or leave a voicemail at 352-236-2211. We will return a call or text as soon as possible.

Personal Information

Name

This address will receive a confirmation email

Phone

Okay to text?

Yes No

Address

Sex

Male Female

Birth Date

Who referred you?

Marital status

Single Engaged Married Separated Divorced Widowed

Last completed education?

Occupation

How long have you had that oppupation?

Partner Information

Please fill out this section with information about your partner or spouse if appropriate.

Name

Phone

Okay to text? Yes No Option

Address

Birth Date

Marital Status Single Engaged Married Separated Divorced Widowed

Occupation

How long have they been at this occupation?

Relationship Diagnostic

Please share the following information about your relationship as is appropriate.

Anniversary

Is your partner willing to come for counseling? Yes No Uncertain

Have you and your partner ever been separated? Yes No

If yes, when and for how long?

Have either of you ever filed for divorce? Yes No

If yes, who and when?

Have either of you been previously married? Yes No

If yes, who and for how long?

How old were you at the time of your marriage?

How old was your spouse at the time of your marriage?

How long did you know your spouse before marriage?

How long did you seriously date one another?

How long were you engaged?

Give a brief statement of circumstances of meeting and dating

Please provide the name, age and gender of each of your children

Family History

Please give us some background on what your family was like growing up.

Describe your relationship with your father

Describe your relationship with your mother

How many siblings do you have?

What is your birth order?

Did you live with anyone other than your parents?

Yes No

If yes, please explain

Are your parents living?

Yes No One yes, one no

If alive, where do they live?

Health Information

Rate your overall physical health

Excellent Good Average Poor Other

If other, please explain

List any important illnesses, injuries, or handicaps

When was your last medical exam?

Have you ever had a hearing screening?

Yes No

If yes, when?

Do you have problems sleeping or being rested after sleeping?

Yes No Sometimes

Do you have any chronic conditions?

Yes No

If yes, please give a brief description

What is your physician's name?

What is your physician's address?

Please list the names and dosages of any medications you are currently taking

Have you ever used drugs for other than medical purposes?

Yes No

lf yes, please explain

Do you drink alcoholic beverages?

Yes No

If yes, please describe how frequently and how much

Do you drink coffee or other caffeinated drinks?

Yes No

If yes, please describe how frequently and how much

Do you use tobacco products? Yes No Option

If yes, please describe what and how frequently

Do you use marijuana or CBD products?

Yes No

If yes, please describe what and how frequently

Have you ever had a severe emotional upset?

Yes No

If yes, please explain

Have you ever had counseling or psychotherapy?

Yes No

If yes, please explain

Are you willing to sign a release of information form so that we may write for social, psychiatric, or medical reports?

Yes No

Religious Information

Did you attend church as a child / teen?

Yes No

If yes, what denomination?

Do you currently attend church?

Yes No

If yes, what is the church's name, location and denomination?

How many times do you attend church in a normal month?

Do you believe in God?

Yes No Not sure

Do you pray?

Yes No

Would you say that you're a Christian?

Yes No Not sure

If yes, how do you know?

How often do you read the Bible? Often Sometimes Never

Does your family regularly read the Bible and pray together? Often Sometimes Never

Have there been any recent changes in your personal spiritual life?

Yes No

If yes, please explain

Diagnostic Questions

Not all of these questions are required for you to answer, but the better answers you provide here the faster we may be able to be helpful in our counselling.

How do you describe the problem(s) that bring you to counseling?

What have you tried to do about it?

Where did you learn that those actions (#2 above) might help?

What recent event brings you here at this time, if any?

What would you like us to do? (Or what are your expectations in coming here?)

What are you willing to do to get this problem solved?

Are you willing to be teachable, honest, do your homework and be in church throughout the counseling process?

Yes No Uncertain

If you answered

When do you tend to experience fear, worry, or anxiety?

Where have you struggled with disappointment?

In what situations do you struggle with anger?

Where do you encounter problems in relationships?

What are the situations of life that you find particularly difficult?

What things do you find yourself seeking to avoid?

Where have you experienced regular problems in your relationship with God?

In what situations do you tend to doubt the truths of Scripture?

What is a good relationship? What do you expect of others?

In what type of situations do you struggle with bitterness?

Where have you struggled with regret, being tempted to say,

In what experiences from the past do you have a hard time letting go?

Where do you tend to struggle with envy? What do you find yourself wanting that others have, and you don't?

Whose opinion really matters to you?

For these last questions, please "fill in the blank."

Life would be all right if ________

I really wish I had ___________

I need ___________

Consent to Counsel

Neighborhood Church Ocala

6474 NE 7th Street

Ocala, Florida 34470

Goals of Counseling:

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 fully enjoy His love for you and His plans for your life.

We trust the Bible:

We believe that the Bible provides sufficient guidance and instruction for faith and life. Therefore, our counseling is based on Biblical principles rather than those of psychology or psychiatry. Neither the pastoral, nor the lay counselors of this ministry are licensed as psychotherapists or mental health professionals and may or may not have degrees or certifications. All our counselors are under the authority of the elders of Neighborhood Church.

Professional Advice:

In the process of biblical counseling there are often times when there is a need for significant advice with regards to legal, medical, financial or other technical areas. In those cases you will be encouraged to seek independent professional counsel. Our pastoral and lay counselors will be happy to cooperate with such advisors and help you consider their counsel in the light of relevant Biblical principles. Some of our lay counselors may be lawyers, doctors or other professionals, but the counselee understands and agrees that such counselors are not providing advice in those areas during the counseling process.

Fees and Resources:

Because we seek to hold God’s gifts with open hands, we want to bless our neighbors by providing these counseling services at no cost. Since the counselors volunteer their time, we can offer the counseling free of charge with the following provisions.

In order to provide good, helpful resources, we ask, if you are able, to pay for the reading materials you will need (usually around $15/resource).

Out of respect for our staff we require a $25 deposit that will be refunded to you should you keep all your appointments or cancel at least 24 hours in advance of your appointment. When you arrive for your first counseling session you will be required to submit this deposit in cash. If you should ever cancel upon less than 24 hours notice, you would forfeit your cancellation fee. You would need to submit another $25.00 before continuing your counseling sessions.

What to Bring:

Please bring with you (one for each person being counseled) a Bible (a modern literal translation such as NASB, ESV, NIV etc. rather than a paraphrase such as The Living Bible), loose-leaf notebook, paper and pen.

Confidentiality:

Confidentiality is an important aspect of counseling, and we will carefully guard the information you entrust to us. There are situations when it may be necessary for us to share certain information with others. Therefore, you agree that our counselors may share certain information:

1) When a counselor is uncertain how to address a particular problem and needs to seek advice from another pastor, elder or counselor

2) When a counselee attends another church, and it is necessary to talk with his or her pastor or elders. Note: if you are a member/attender of Neighborhood Church, the fact you are receiving counseling may be shared with the Pastor-Teacher to assist him in shepherding the flock.

3) When there is a clear indication that someone, including you, may be harmed unless others intervene

4) When required by laws of the State of Florida and the United States of America

5) When a person persistently refuses to renounce a particular sin, and it becomes necessary to seek assistance of others in the church to encourage repentance and reconciliation (for descriptions of this Biblical principle please see Matthew 18:15-20 and Proverbs 15:22; 24:11).

Please be assured that our counselors strongly prefer not to disclose personal information to others, and 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, we require all of our counselees to agree that any dispute that arises with a counselor or with the church as a result of counseling, will be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure of the Institute for Christian Conciliation, a division of Peacemaker® Ministries (complete text of the Rules is available at www.Peacemaker.net). Judgment upon arbitration award may be entered in any court having jurisdiction.

The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and expressly waive their right to file a lawsuit in any civil court against one another for such disputes, except to enforce an arbitration decision.

An executed facsimile copy or e-mail delivery of a “.pdf” format data file shall be an acceptable form of acceptance of this Consent.

If you have any questions about these guidelines, please talk with Michael Lockstampfor, pastor of Neighborhood Church Ocala miklocks@gmail.com, (352) 421-1243.

I/WE HAVE READ AND UNDERSTAND THE ABOVE PROVISIONS, AND I/WE UNDERSTAND THEM AND I/WE HEREBY ACKNOWLEDGE AND AGREE TO ALL OF THE ABOVE TERMS, INCLUDING, BUT NOT LIMITED TO, THE CANCELLATION POLICY, WAIVER OF SEEKING REDRESS (LAWSUIT) IN THE CIVIL COURT SYSTEMS, AND AGREEING THAT ANY AND ALL DISPUTES BE RESOLVED THROUGH RESOLUTION AS DETAILED ABOVE.

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Application for Biblical Counselling

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