PDI Form for Ages 17 and under

PERSONAL DATA INFORMATION FORM (PDI)

Please fill out this form to request counseling/mentorship with The Chapel. You will be contacted within 7-10 business days. This form IS NOT for situations requiring an IMMEDIATE response.

-Please have the child complete the form. We are looking for their point of view.

-Please have the adult and child read and complete the Informed Consent and Counseling agreement after the information part is finished.

IF THERE ARE THOUGHTS OF SUICIDE OR SELF HARM:

- Call or text 988 to reach the National Suicide Prevention Hotline available 24 hrs/day

-or Erie County Kid's Helpline (716) 834-1144

Please note: We provide caring, biblically based counseling and mentorship in an effort to help you and your family face whatever you're navigating through the lens of the gospel. We do not provide licensed, professional counseling, but will refer as needed. You will be asked if you have read and agreed to the "Counseling Agreement" and "Informed Consent" below before your first meeting.

IDENTIFICATION DATA

ALL INFORMATION IS CONFIDENTIAL. Please have child complete as much information as possible on this form, we are looking for their point of view. Please write "N/A" when information does not apply, "U" when information is not known.

Child's First Name:

Child's Last Name:

Parent(s)/Guardian(s) name:

Address:

City:

Zip:

(C)

Phone:(H)

(W)

Parent Email:

Gender:

Birthdate:

Age:

School Name:

Grade:

Referred here by:

Health Information

List any important health information we should know:

for ex: overall health, major illness or injuries, weight changes, substance use

Church Activity

Do you attend The Chapel?

Yes

No

Which Campus do you regularly attend?

CrossPoint

Lockport

Cheektowaga

Niagara Falls

Partner Church

How long have you been attending The Chapel?

How often do you attend per month?

Do you attend a different church?

Yes

No

Name of other Church:

How long have you been attending?

Do you attend Chapel Kids, Chapel Students, or another youth group?

Yes

No

What do you believe about God?

How would you describe your relationship with Christ?

Personal Information

Have you ever had counseling before?

Yes

No

If yes, list counselors or therapists and dates:

What was the outcome?

Who lives in your home? What can you tell us about your family?

How much time do you spend on a screen(in hours)on an average day that is not school related? (phone, computer, tablet, tv, video games)

0- 1 Hour

1 Hour - 3 Hours

4 Hours - 6 Hours

7+ hours

What do you do during screen time? What apps, social media, music, or videos do you use or watch?

Briefly Answer the Following

Problem Check List (Check all that are current for you):

Anxiety

Depression

Suicidal thoughts

Self-harm (cutting)

Anger

Fear

Moodiness

Bitterness

Eating related issues

Guilt

Grief / Loss of loved one

Rebellion

Change in lifestyle

Health

Bullying

Relationship Problems (please specify)

Use of drugs (including marijuana & illegal substances)

Use of alcohol

Desire to hurt others

Sexuality/ Gender

Abuse- physical

Abuse- spiritual

Abuse- emotional

Abuse- sexual

Stress in the home

Trauma

Type of Relational Problem

Problems with parent(s)

Problems with sibling(s)

Problems with other kids/friends

Problems with adults "in charge"

Of the above items checked, which are the biggest problems? Please explain.

Tell us why you are seeking biblical counseling.

What have you done in the past to deal with your issue(s)?

What goals do you have for counseling? What do you expect to accomplish with our help?

Is there any other information we should know that will help us to help you?

Our available office hours for appointments are Mondays and Fridays from 9am - 5pm and Tuesday, Wednesdays and Thursdays from 9am to 7:30pm. What days and hours would you be available for an appointment? (Please put as many availabilities as possible)

Informed Consent and Counseling Agreement Form

The Pastoral Care Ministry of The Chapel offers biblically based counseling to provide spiritual care, support, encouragement, and referrals when determined necessary in a safe and confidential manner. Support is typically on a short-term basis during times of significant need or crisis. During this timeframe, the intent is to help bring clarity to the issues involved and define the priorities of care. After this initial care, ongoing discipleship/mentorship can be considered.

The volunteer lay counselors are trained and under the direct and general supervision of the Pastoral Care Team Leader, the Biblical Counseling Director, and the Children's Counselor at The Chapel. Regardless of their education, training, licensure or expertise, The Chapel's lay counselors do not function in a professional role and do not provide clinically oriented mental health treatment or therapy.

The Chapel values the role of the family. We believe that the parental and family role is special and commissioned by God. Therefore, when providing care to minor children, we will take a family focus when at all possible.

Confidentiality

All communications, records, and contracts with The Chapel's lay counselors will be held in strict confidence. Information may be released in accordance with the laws of New York only when:

1. The care seeker and/or guardian (if care seeker is under the age of 18 years of age) signs a written release of information indicating informed consent to such release; or

2. The care seeker expresses serious intent to harm himself/herself or someone else; or

3. There is evidence or reasonable suspicion of abuse against a minor child, elder person (65 years or older) or a dependent adult; or

4. There is evidence demonstrating a gross distortion of reality or the ability to function in normal daily routines; or

5. The Chapel's lay counselor feels that counsel, assistance, and/or supervision may be required from the Pastoral Care Team Leader, Biblical Counseling Director, or Children's Counselor.

Counseling Agreement

Expectations:

I understand that confidentiality cannot be guaranteed in the case of information outlined above.
I understand that biblical counseling is offered at no cost for those who attend one service a week at The Chapel (or other Bible-believing church). Therefore, I commit to attend The Chapel (or other Bible-believing church) each week while I am receiving counseling. If from another church, The Chapel must receive acknowledgment from the pastor.
I understand that all biblical counseling will be provided by a pastor, a qualified staff member, or a lay counselor who will counsel based upon their training and understanding of Scripture, not as licensed therapists.
Counseling/Mentorship care for minors (ages 17 and under) requires the first session to be between parent(s)/guardian(s) and counselor only. The minor is not to attend.
The family is required to be a part of the care.
I will keep the appointment time or will call to cancel in advance with a legitimate reason.
I understand that age-appropriate activities and assignments will be assigned as needed. Activities may involve games, interactive play, art, music, individual and family sessions.
The counselee and family will complete any assignments.
I understand that session(s) may be terminated at any time by either party.
Children ages 12 and under: there will be 2 adults present at all times and the sessions will be held in a room with a window. It may be required that a parent is the second adult.

I/we, the undersigned care seeker(s) or guardian(s), have fully read, fully understand, and agree to the conditions of this Informed Consent and Counseling Agreement Form and acknowledge that by signing below.

Signed by youth

Date

Signed by Parent or Guardian over the age of 18.

Date

Signed by Parent or Guardian over the age of 18.

Date:

The Chapel is on mission to reach every Man, Woman & Child with repeated opportunities to hear and see the Gospel of Jesus Christ.