PDI Form for Hope Bible Church

Completed: 0%

Note: If a question on the form does not apply, please leave it blank.

Name

Address

Address Line 2

City

State/Province

Zip/Postal Code

Primary Phone

Secondary Phone

Email * This will allow you to receive a copy of the completed form.

Referred By

Birth Date (MM/DD/YYYY)

Gender: Male Female

Completed Education

Marital Status

Employer

Position

Years at Employer

Is English your first language?
Yes No If not, what is?

Completed: 12%

What is the main problem, as you see it? What brings you here? - required

What have you done about the problem? - required

What are your expectations in coming for counseling? - required

Is there any other information that we should know?

Does anyone from your church plan to accompany you to counseling? Yes No

If Yes, please indicate his/her name(s), and the nature of your relationship with them.

Completed: 24%

Spouse

Birth Date (MM/DD/YYYY)

Occupation

Years at Employer

Primary Phone

Secondary Phone

Email

Date of Marriage (MM/DD/YYYY)

How long did you date?

Circumstances of meeting and dating (brief)

Is your spouse willing to come for counseling? Yes No If not, please explain

Is your spouse in favor of your coming? Yes No If not, please explain

Have either of you been previously married? Yes No If so, to whom?

Have you ever been separated? Yes No

Have you ever filed for divorce? Yes No

If there have been multiple marriages, briefly explain time frames, children involved, and reasons.

Information About Children:

Additional Children (separate information with commas, one row per child.)

Describe your relationship to your parents

Number of Siblings

Birth order of all siblings

Did you live with anyone other than your parents growing up?

Are your parents living? Do they live locally?

Completed: 36%

Describe your health

Do you have any chronic conditions (pain, headaches, insomnia, etc.)? Yes No If so, what:

List important illnesses and injuries or handicaps

Approximate Date of last exam:

What was the report?

Physician's name and address

Current medication(s) and dosage

Have you ceased taking any drugs recently? Which ones, why, and when?

Have you ever used drugs for anything other than medical purposes? Yes No If so, explain

Have you ever been arrested? Yes No If so, why, when, and was there a resulting sentence?

Do you drink alcoholic beverages? Yes No If so, how frequently and how much

Do you drink coffee? Yes No How much?

Other caffeine products consumed

How much?

Do you smoke? Yes No What: Frequency:

If you have ever had interpersonal problems on the job, please describe them

Have you ever had a severe emotional upset? Yes No If yes, please explain

Have you ever seen a psychiatrist or counselor? Yes No If yes, how was it helpful? Please explain

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records? Yes No

Completed: 48%

Denominational Preference

Church attending I am a member

Location

Pastor's Name

Pastor's Phone Number

Do we have permission to contact your pastor? Yes No If not, please explain why: * Permission to contact your pastor includes sharing information on this PDI.

Church attendance per month:

Do you believe in God?     Yes    No
Do you pray?     Yes    No
Would you say that you are a Christian?     Yes    No    Or interested in becoming a Christian:     Yes    No    Have you ever been baptized?     Yes    No

How often do you read the Bible?

Explain any recent changes in your spiritual life

Completed: 60%

Have you had any menstrual difficulties: Yes No

If you experience tension, tendency to cry, other symptoms prior to your mestrual cycle, please explain

Have you ever had an unplanned pregnancy? Yes No

Have you ever had an abortion? Yes No

If you had an abortion, did you suffer any medical side-effects that would be helpful for your counselor to know?

Completed: 72%

Please select areas you are struggling with.

Completed: 84%

Before Beginning Biblical Counseling

In order to make our first session as profitable as possible we would ask you to give careful attention to the following items. If you have any questions regarding the content of this agreement, please call the church office and we will be glad to answer any questions you might have. If you are unable to complete these before our first scheduled meeting, please call to reschedule your appointment.

If you are unfamiliar with biblical counseling, please click here to understand the kind of counseling we offer.

Consent and Commitment to Biblical Counseling

Our Goal — 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 enjoy fully His love for you and His plans for your life.

Biblical Basis — We believe that the Bible provides guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of secular psychology or psychiatry. The counselors of this ministry are neither licensed as psychotherapists or mental health professionals. It should be understood that biblical counseling consists of the giving of scriptural counsel and the practical application of the Bible to each individual. Yet, the counselee is held fully responsible for how he or she implements that counsel.

We are confident that the Bible has all of the information necessary for life and godliness (2 Pet. 1:3). There are no problems between people that the Bible fails to address either in general or specific principles. Our counselors are not infallible, nor do they pretend to know all there is to know about biblical teaching and its applications to life, but they are well equipped and competent to help people change. They will make a point to differentiate between God's commands and their suggestions.

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 by your counselor to seek independent professional advice. Our counselors will cooperate with such advisors and help you to consider their advice in the light of relevant scriptural principles.

Confidentiality — Confidentiality is an important aspect of the counseling process and we will carefully guard the information you entrust to us.

However, absolute confidentiality is not biblical; in certain circumstances the Bible requires that facts be disclosed to selected others (Matt. 18:15ff). If church leadership should inquire about your situation, we will disclose to them only that information which we believe is necessary for them to effectively and biblically fulfill their responsibility to shepherd you.

There are five situations when it may be necessary for us to share certain information with others: 1) when a counselor is uncertain how to address a particular problem and needs to seek advice from another pastor or counselor; 2) when a counselee attends another church and it is necessary to talk with his or her pastor or elders, 3) when there is a clear indication that someone may be harmed unless others intervene, 4) when a person persistently refuses to renounce a particular sin and it becomes necessary to seek assistance from others in the church to encourage repentance and reconciliation (see Matthew 18:15-20; Proverbs 15:22; 24:11) or 5) when criminal activity has been committed and the counselee refuses to bring the matter to the attention of local authorities. 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, we require all of our counselees to agree that any dispute that arises with a counselor 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; judgment upon arbitration award may be entered in any court having jurisdiction. (We will be happy to provide you with booklets that explain that Christian conciliation process and describe its benefits and procedures.)

Termination of Counseling — It is our desire that the counseling arrangement will conclude with a resumption of healthy participation into the church and your life contexts. However, at any time during the counseling process, the counselor or counselee, has the option to terminate the counseling arrangement.

Expectations and Commitments — As your counselor invests in you, he will also have some expectations of you. First, it is important that you be honest and be willing to trust your counselor. It will be very difficult to find help if you seek to hide or deceive away from the hard truth of your situation. Second, your counselor will regularly send you away from each meeting with a bit of homework. Since the hard work of change happens more outside of the counseling meeting, this homework will be purposeful and necessary to work toward genuine and lasting change. Last, your counselor will be looking for a commitment of time. Problems and bad habits develop over long periods of time and often cannot be broken in a matter of days. For this reason, your counselor will be looking for a commitment to attend regular meetings.

Normally, counseling sessions will last from one to one and one half hours each week or bi-weekly and will continue until as long as it is necessary, appropriate, and helpful to do so. If you accept and apply the counsel you are given, in most cases counseling will last less than 12 sessions. However, if the counselor does not observe noticeable change in heart, mind, or action in the first few weeks, he or she will seek to identify the cause and discuss it with you to help you to correct it.

If you are unable to come to any of the counseling sessions, please notify your counselor as soon as possible. You can help the counselor make wise use of their time by letting them know in advance that you cannot make it.

In order to achieve lasting victory over the problems of life, it is vital that each person becomes established in a consistent Christian walk. The Lord has provided the local church to help in this process (Heb. 10:24-25). Therefore, it is important that counseling sessions be accompanied by church activities that encourage discipleship and fellowship. For this reason, as part of your counseling we request that you attend at least two services or ministries each week (e.g., a weekly worship service and a Sunday school class). We also strongly encourage HBC members to join a small group which meets on various days during the week.

You will need a notebook and your Bible at all sessions, including the first. Be sure to bring them each time. Come with high expectations! You will find hope and encouragement even during your first session. From then on, with your cooperation, we are confident that you will find the true, good and acceptable answer to the difficulty that prompted you to come to us.

Having clarified the principles and policies of our counseling ministry, we 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 Pastor Gabe.

Electronic Signature

I, (electronic signature required), have carefully read the conditions for counseling set forth on this page and agree to enter into counseling in accordance with them.

I am filling out this form on behalf of the counselee:

My Name

Relationship

Completed: 100%

Thank you for taking the time to fill out this form! Your complete and honest answers will aid the counseling process and allow us to better understand you and your situation.

We encourage you, if you have not already, to go back and review your answers. Once you click "Finish" an email will be sent to our counseling office. If you filled in your email address under the Personal section, you will receive a copy of your PDI.

If we have not already done so, we will contact you soon to set up a meeting time and to give you more information regarding our counseling together. Again, if you have any questions or concerns, please contact Pastor Gabe at (443) 200-HOPE (4673), or counseling@hopebible.org

* If you do not see a confirmation message after clicking "Finish,", scroll up and review the form to ensure any required questions are answered.

Click "Finish" to submit your Personal Data Inventory.