PDI Form for Trinity 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?

What have you done about the problem?

What are your expectations in coming for counseling?

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%

Policies, Procedures and Liability Form

Whereas the parties acknowledge that the counseling services provided are Biblically based and are not part of a licensed discipline governed/regulated by any governmental agency, and;

Whereas the parties acknowledge that the counseling services and confidentiality of the same is conditional for which the Counselee gives authorization and full release of Counselor upon the disclosure of information should contingencies arise that require the same as outlined herein below;

Now therefore, the parties further agree as follows:

Our Goal: The mission of Trinity Counseling and Training Center is to equip you to meet the challenges of life by the transforming power of Jesus Christ for the glory of God. We offer counseling free of charge as a ministry of Trinity Bible Church. Counselees may donate to the ministry, but this is not expected or required as a condition of counseling. You have no express or implied obligation to pay other fees for the counseling you receive.

Biblical Basis: Trinity Counseling and Training Center counseling is strictly religious in nature, conducted under the authority and leadership of the church. We believe that God, through His revelation in the Old and New Testaments of the Bible, has provided His people with thorough guidance and instruction for faith and life (II Timothy 3:16-17; II Peter 1:3-4). Our counseling is based solely on scriptural principles. Trinity Counseling and Training Center counselors are not licensed as psychotherapists or mental health professionals, and under Wyoming law (W.S. 33-38-103) no such licensing is required.

Other Professional Advice: If you have significant medical, legal, financial, or other technical questions, you should seek advice from a competent independent professional. Our counselors will cooperate with such advisors and help you to consider their counsel in the light of scriptural principles.

More specifically, we urge our counselees to properly care for their physical bodies and to seek proper medical treatment for all physiological problems. Our counselors will assist you in responding to such problems in a godly manner, but our counsel is not intended to replace the services of a qualified physician where organic problems are present or where medication has been prescribed.

Confidentiality The counselor is very sensitive to the issue of confidentiality. Confidentiality is crucial to an effective and trusting counseling relationship and the counselor will carefully guard the information Counselee entrusts to him/her. There are situations, however, in which the discipleship Counselor may believe that it is wise or mandated (Biblically and/or legally) for them to share certain information with others.

There are seven (7) situations where it may become necessary for Counselor to share certain information with others.

By signing this agreement Counselee acknowledges that they are pursuing a form and course of counseling that is in conformity with their faith and Biblical orientation and desire the same to be provided and is being provided in relation to the church community they have voluntarily engaged and further authorizes the Counselor to share information with others in the following limited circumstances:

When a discipleship Counselor is uncertain how to address a problem and needs to seek advice from another pastor or counselor. The specific name and particular information will be generalized so that the other consultant doesnt know who the Counselor is counseling (Proverbs 11:14; 24:6).
When there is concern that someone may be harmed and abused unless government officials intervene (Romans 13:1-7).
Adult and Domestic Abuse: If we have reasonable cause to believe that an adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency which provides protective services. If you express a serious threat, or intent to kill or seriously injure an identified or readily identifiable person or group of people, and we determine that you are likely to carry out the threat. We must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent and/or appropriate criminal agencies.
Child Abuse: If we have reasonable cause to suspect abuse of children with whom counselor comes into contact we will report this to the appropriate governmental agencies.
When counseling someone who is under familial authority (e.g. wife to husband, child to parent) the counselor may encourage the Counselee to inform their familial authority and/or the Counselor may inform them (Ephesians 5:22- 6:4).
When a person refuses to renounce a particular sin, and seeks to continue in counseling with the counselor, it will become necessary to seek the assistance of others in the Counselees church to encourage repentance and reconciliation and/or to begin the process of church discipline (Proverbs 15:22, 24:11; Matthew 18:15-20).
When discussing the information with the observers sitting in on the counseling sessions to assist the Counselor or for training purposes.

Please be assured that our counselors strongly prefer not to disclose your personal information to others (if not needed), and they will make every effort to help you find ways to resolve a problem as privately as possible.

Conflict Resolution - Arbitration: On rare occasions, a conflict may develop between a counselor and counselee. First Corinthians 6:1-8 forbids Christians from bringing lawsuits against one another in secular courts of law. In order to ensure that such conflicts are resolved in a biblically faithful manner, we require all of our counselees to agree that any dispute with a counselor or with this church will be settled by mediation and, if necessary, legally binding arbitration conducted in accordance with Rules of Procedure of the Institute for Christian Conciliation. The arbiters will be the elders of Trinity Bible Church. If one or more elders of the church is a party to the dispute, then three arbiters will be selected from the elders of like-minded churches, with each party to the dispute choosing one arbiter, and the two arbiters then selecting the third. It is expressly understood that, by consenting in advance to such arbitration, the counselee is waiving his right to a trial in the civil courts. By signing this consent, you agree that you will not attempt to subpoena or require any counselor to appear in any legal proceeding related to any matters discussed during counseling; nor will you attempt to subpoena any notes or records related to this counseling.

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 grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about these guidelines, please speak with your counselor. Your signature below indicates your informed consent to these guidelines.

As a precondition to any and all counseling services to be provided by the counselor, the undersigned, in consideration of the services provided by the counselor, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the counseling relationship/services as a direct or indirect result of any involvement Client may have with the counselor or the counselors church or any other partnering/hosting church.

Client further understands that it is the specific intent and purpose of this legal document to release and discharge any and all claims and causes of action of any kind or nature which are directed toward a Counselor, Pastor or Church. This includes causes which are known or unknown, specifically mentioned or implied, or not mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document. The undersigned further specifically waives any claims or right to assert that any cause of action or claim or demand has been, through oversight or error, intentionally or unintentionally omitted from this release. The undersigned also understands that the Counselor is a certified Biblical counselor and/or has been trained in Biblical counseling, but is not state licensed and not under the regulatory authority of any governmental agency. Also, when the term counseling or counselor is mentioned above it does not refer to psychiatric or psychological state licensed professional, psychiatric, legal or clinical medical advice provider. The advice given is based on how to think rationally and clearly from a Christian Biblical perspective only. The nature and source of all information given comes from the Bible and therefore is Biblical counseling or sometimes referred to as Biblical Counseling, Discipleship Counseling or Counseling.

Electronic Signature

I, , 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 the counselor 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 the counseling office at Trinity Counseling and Training Center. If you filled in your email address under the Personal section, you will receive a copy of your PDI.

Your counselor will contact you to set up a meeting time and location that is convenient for both parties. If you have any questions or concerns, please do not hesitate to contact our counseling office.

Click "Finish" to submit your Personal Data Inventory.

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