Counseling Request Form - Biblical Counseling of the East Valley

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alternate Phone

Email*

How would you like to receive appointment reminders?*

Phone Call
Email
Text Message

Date of Birth*

Gender*

Male
Female

Occupation

Martial Status*

Spouse's name (If applicable)

Children names and ages (if applicable)

Who is the counseling for?*

Self
Both me and my spouse
My child

How did you hear about us, or who referred you?*

What times are you available Monday through Thursday?*

Do you have any physical or medical conditions? If so, please explain.

What church do you regularly attend?

Are you a member? In what ways are you involved in this church?

If you were to die tonight and stand before God and He asked you why He should permit you to enter heaven, what would you answer?

Who are your two closest friends and why?

Do you have a close Christian friend who, if needed, could come with you to the counseling center for support, encouragement, and accountability between sessions?

yes
no

Have you received counseling in the past?

yes
no

Who, when, and for how long? Can you summarize what they believed the main problem to be and what they told you to do about it?

What is the main problem/trouble as you see it? (i.e. What needs to change?) How long has this been going on?*

For this form, this only needs to be a brief description.

What things do you think have contributed to the problem/trouble? Do you believe you have in some ways contributed to the problem/trouble?

For this form, this only needs to be a brief description.

Please describe anything you have done about this problem so far. What were the results?

What would you like us to do?*

Distinctives and Consent to Counsel*

Our Confidence & Counseling We at the Biblical Counseling of the East Valley are confident that the Bible contains all the necessary information for your life and your need for godliness (2 Peter 1:2-4). We do not need to go outside its pages to find the answers. Though it is not a medical book, it is a spiritual, relational, and behavioral book from God Himself. When God’s Word speaks to our problem or trouble, it is the authority in explaining why the problem exists. There is no other book or counsel so worthy of our attention as we seek explanations and solutions to all our woes. Those who put their hope in His Word will never be ashamed. If we follow His counsel, we will always be led in the right way – to a deeper faith and practical obedience in Jesus Christ. Simply stated, the Bible guides us through our problems to Jesus Christ. There is not and never will be another counselor more wise, more powerful, more loving, more insightful, and more worthy than Him. In Him, we will find all we need. He is sufficient and His Word is sufficient in leading us to Him. What You Can Expect 1) We will carefully gather all of the information needed to understand your unique situation 2) You will receive biblical hope and encouragement that your problems can be solved 3) You will gain biblical insights into the root causes of your problems 4) You will learn to think and respond to your trouble in ways that will lead to lasting changes and solutions. 5) Most counseling situations require 6-10 sessions. Our Expectations Please bring your Bible and notebook to take notes, ready to prayerfully work on specific changes God’s Word prescribes for you. You will be asked to complete homework during the week between sessions. Each assignment will be relevant to your presenting problem and will help you find biblical resolution more quickly. It is important for you to attend a Christian church that believes and teaches God’s Word clearly and unashamedly. Fellowship with God’s people is essential to promoting and sustaining the things God will be doing in your life through biblical counseling. In some cases, and with your approval, we will ask another mature Christian to join us in the counseling process for the purpose of supporting you more personally through prayer and relationship. Confidentiality Policy The Bible clearly says gossip is sin. Therefore, BCEV will not release information about particular counselees except in the few situation required by the Bible or the laws of our state. Those situations are: 1) When someone is in danger of being harmed 2) When a child or elder over the age of 65 is physically or sexually abused 3) When someone persistently refuses to stop a sinful pattern and it is necessary to seek assistance from his/her church to encourage proper change (Matthew 18:15-20 and Romans 13:1-7) COST: We do not want financial reasons to keep anyone from receiving biblical counseling. Instead of having a set fee for counseling sessions is sustained by charitable donations. Late Cancellation or Missed appointment Policy * Please note that we require a minimum 48 hour notice if you will not be able to attend your scheduled appointment. This Policy allows BCEV to give the time to someone who is on our waiting list. You can cancel via telephone/voicemail, text message at (602) 628-5015 or email at info@bcev.org.

I Understand

Please check each box below which indicates that you have read and agree to these things.*

I agree not to subpoena or require any biblical counselor to appear in any legal proceedings related to any matters or any persons discussed in any counseling appointments; Furthermore, I agree not to attempt to subpoena any notes or records related to the counseling process.

I understand that I may be asked to allow two counselors to work together with me on helping me find biblical solutions to the problems. This is because of the benefits to the counselees that this team approach has produced. The primary counselor will be a staff biblical counselor, but a team counselor may join him. A team counselor is an intern who has been through the BCEV counseling training program and is in the process of national certification under the supervision and mentorship of the director, Tom Angstead.

I understand BCEV counselors do not use psychological models or insights to help me with explaining or solving my problems and may or may not be psychologically trained, but rather biblically trained to counsel. I understand BCEV seeks to use the Scriptures to interpret, instruct, and inspire solutions.

If you currently attend a local church: BCEV is passionate about one another care. We believe this happens within the context of the local church, and that pastors are the shepherds entrusted with soul care (1 Pet 5:1-4; Heb 13:17). The qualified counselors and staff at BCEV focus on strengthening the church by offering high-quality training classes and training materials. We can help provide counsel; however, if you are part of a local church, we require your pastor/elder’s assistance in helping you. Your pastor must be willing to attend your counseling appointments.

If you are not currently attending a church: A requirement for receiving biblical counsel from BCEV is that you begin attending the church of the counselor assigned to you. We believe being part of a local church is necessary for every believer’s spiritual growth.

CONSENT AUTHORIZATION*

I have read and agree with all of the information on this document and hereby willingly consent to receive biblical discipleship and biblical counseling with Biblical Counseling of the East Valley (BCEV). This agreement may be executed via electronic signature; and any electronic signature shall be considered the equivalent as wet ink.

Counselee First Name Counselee Last Name

Is the counselee under 18?*

yes
no

GUARDIAN NAME*

If counselee is under the age of 18, guardian authorization is necessary.

Guardian First Name Guardian Last Name

Guardian Phone Number*

How urgent is your request for counseling?*

As Soon As Possible
Within the Next Few Weeks
Within the Next Month