PDI Form for Ages 9 to 12

IDENTIFICATION DATA

Child's First Name:

Child's Last Name:

Parent(s)/Guardian Name:

Address:

City:

Zip:

Parents Phone: (H)

(C)

(W)

Parents Email:

Child's Gender:

Birthdate:

Age:

Child's School Name:

Grade:

Referred here by:

Health Information

Rate Your Health:

Very Good

Good

Average

Declining

Other

Have you had significant weight changes recently, gain or loss?

Gained Weight

Lost Weight

List all important present illnesses, past illnesses, injuries or handicaps:

Are you presently taking any prescription medications?

Yes

No

What?

Why?

Church Activity

Do you attend The Chapel?

Yes

No

Which Campus do you regularly attend?

CrossPoint

Lockport

Cheektowaga

Niagara Falls

Partner Church

How long attending The Chapel?

How often do you attend per month?

Do you attend a Partner Church?

Yes

No

Name of Partner Church:

How long have you been attending?

Do you attend a youth group?

Yes

No

If yes, which one?

Do you believe in God?

Yes

No

Uncertain

Would you say you are a follower of Christ?

Yes

No

Do you believe Satan exists?

Yes

No

Uncertain

Do you spend regular time with God in prayer and reading the Bible?

Yes

No

How often do you read the Bible?

Never

Occasionally

Often

How often do you pray to God?

Never

Occasionally

Often

Explain recent changes in your walk with God:

Personal Information

Please select the words that best describe you:

Godly

Angry

Unreasonable

Abusive

Irresponsible

Cruel

Uneducated

Proud

Embarrassing

Active

Ambitious

Self-confident

Persistant

Nervous

Hardworking

Impatient

Impulsive

Moody

Often sad

Excitable

Imaginative

Calm

Serious

Easy-Going

Shy

Good-natured

Introvert

Extrovert

Likable

Leader

Quiet

Hard

Submissive

Lonely

Self-conscious

Sensitive

Funny

Sloppy

Well-groomed

Self-disciplined

Whiner

Selfish

Lots of friends

Failure

Success

Other

Have you ever had counseling before?

Yes

No

If yes, list counselors or therapists and dates:

What was the outcome? Do you feel it helped you?

Is there anything you are afraid of or fear?

Have you recently suffered a loss from a serious relationship?

Yes

No

If yes, please explain:

List anyone who you hate or are extremely angry with, and why:

Were you ever sexually abused by anyone?

Yes

No

Please Detail:

Were you abused by a relative?

Were you abused by a stranger?

Were you abused by a neighbor?

How old were you at the time?

Was the person ever proecuted?

Yes

No

Is there any other information that you would like to share at this time?

Family and Childhood Information

How many brothers do you have?

How many sisters do you have?

What number child are you in the birth order?

Are you on good terms with your father, mother, siblings? If not, list who you're not on good terms with and why:

What kind of home are YOU growing up in?

Traditional (Father, Mother, Kids)

Authoritarian (Father or Mother made all rules without discussion and would not allow for other opionions.)

Single or Divorced Parents

Alcoholic (One or Both Parents or sibling alcohol addicted)

Drug Affected (One or Both Parents or sibling drug addicted)

Perfectionist (Everything needed to be perfect to please Mom or Dad)

Critical (One or both parents always remark on negatives and offered little praise for the good)

Affectionate (Free with hugs and kisses)

Emotional (Crying and/or anger freely allowed)

Repressed (Emotions never allowed to show)

Religious (For real, not faked for appearance. A real realtionship with God)

Fake Religious (Only religious for appearance, but behind closed doors no real relaationship with God)

Step Family (One or both parents remarried)

Abusive (Verbal, Emotional, Physical, Sexual)

Have you been or are you being raised by anyone other than your biological parents?

Yes

No

If yes, briefly explain by who and why:

How would you describe your fathers personality? (ex. Godly, Worldly, Strict, Easy-Going, Moody, Calm, Serious, Humerous, Lazy, Hard-Working etc.)

How would you describe your mothers personality? (ex. Godly, Worldly, Strict, Easy-Going, Moody, Calm, Serious, Humerous, Lazy, Hard-Working etc.)

Which parent do you feel closest to and why?

What kind of community are you growing up in?

Urban Area

Suburban Area

Small Town

Rural

City, State

What is your families economic situation?

Extermely poor

Poor

Lower middle

Middle

Higher middle

Wealthy

Exteremly Wealthy

What has been your happiest memory?

What has been your unhappiest memory?

Have you experienced a major trauma? (ex. at home, at school, at a neighbor's home, at a relatives home. Please explain:

Screen Time

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

1 Hour - 3 Hours

4 Hours - 6 Hours

7 Hours - 9 Hours

10 Hours - 12 Hours

13 + Hours

What sort of activities do you watch, listen to, or participate in within that time?

Personal Behavioral Habits

Do you drink coffee or other caffenated drinks?

Yes

No

If yes, how much per day?

Do you smoke/vape or chew tobacco products?

Yes

No

If yes, how much per a day?

Do you use maijuana or other drugs?

Yes

No

If yes, how often?

Occationally

Often

Very Often

Do you drink alcohol?

Yes

No

If yes, how often?

Occationally

Often

Very often

Do you have problems sleeping?

Yes

No

How many hours of sleep do you get on an average night?

How many times a week do you eat fast food or take out?

What is your general activity level?

Low

Moderate

High

Do you ever explode when you get angry or hurt?

Yes

No

Do you withdraw when you get angry or hurt?

Yes

No

Do you frequently ague with people?

Yes

No

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

Anger

Envy

Appetite

Anxiety

Fear

Memory

Apathy

Gluttony

Moodiness

Bitterness

Guilt

Rebellion

Change in lifestyle

Health

Homosexuality

Parents

Depression

Abuse

Deception

Bullying

Other

Of the above items checked, which one(s) seem to be the most dominant?

Briefly Answer the Following

What issue(s) may we help you with?

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

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 8:00pm. 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 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 to help bring clarity to the issues involved and defined the priorities of care. After this initial care, ongoing discipleship/mentorship can be considered. The volunteer lay counselors are trained and under the direction and general supervision of the Pastoral Care Team Leader and the Biblical Counseling Director at The Chapel. Regardless of their education, training, licensing 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.

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 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 or Biblical Counseling Director.

Counseling Agreement

Assignments/Accountability: Counselees make more rapid progress when they are required to study or to perform specific informational or behavior assignments which pertain to the problem. We tailor these assignments to the individual counselee and the circumstances. We are not interested in wasting the time of the counselors or the counselees. We are interested in helping people learn how to experience the peace and joy that result from a walk of thankful obedience to God's Word, and we hold the counselees accountable for doing the assignments on schedule.

How much does it cost? The Chapel's Counseling Ministry is available at no cost for those who attend one service a week at The Chapel (or other Bible-believing church)

Conditions:

I will keep the appointment time, or will call to cancel in advance with a legitimate reason.
I will fulfill any assignments.
I will attend The Chapel (or other Bible-believing church) each week while I am receiving counseling. If from another church, we must receive the pastor's acknowledgement.
I understand that confidentiality cannot be guaranteed in the case of information as indicated above.

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

Signed (Child)

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.