Personal Data Information Form (Adult)

About the Ministry

The Chapel offers biblical 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 (6-10 sessions) during times of significant need to help bring clarity to the issues involved and define the priorities of care.

The volunteer lay biblical counselors are trained and under the direction and general supervision of the Director of Biblical Counseling and the Director of Care Ministries at The Chapel. Regardless of their education, training, licensure or expertise, The Chapel's lay biblical counselors do not function in a professional role and do not provide clinically oriented mental health treatment, therapy, or crisis intervention.

IMMEDIATE ASSISTANCE

For thoughts of self-harm or suicide:

-Call or text 988 to reach the National Suicide Prevention Hotline available 24 hours a day

Confidentiality

All communications, records, and contracts with The Chapel's lay biblical 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 Director of Biblical Counseling or the Director of Care Ministries

Counseling Agreement

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. Depending on the capacity of our team, we may be able to assist those who attend another Bible-believing church, with the acknowledgement and agreement of their pastor.

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 Counseling Agreement that by signing below.

Type your name to acknowledge that you have read and agree to the above:

Identification Data

First Name:

Last Name:

Address:

City:

Zip Code:

Occupation:

Place of Employment:

Phone: (H)

(C)

(W)

Email Address:

Gender:

Birthdate:

Age:

Education: (in years)

Referred here by:

Which Campus do you regularly attend?

How long have you been attending The Chapel?

For how long have you been attending?

Marriage and Family Information

Relational Status:

Date of Marriage:

Your ages when married: Husband

Wife

How long did you know your spouse before dating?

Length of steady dating with spouse:

Length of engagement to spouse:

First Name of Spouse/Partner:

Last Name of Spouse/Partner:

Gender:

Male

Female

Spouse's Address:

City:

Zip Code:

Spouse's Occupation:

Spouse's Place of Employment:

Phone: (H)

(C)

(W)

Your spouse's age:

Education: (in years)

Religion:

Is your spouse willing to come in for counseling?

Yes

No

Have you ever been separated?

Yes

No

If so, when?

Have either of you ever filed for divorce?

Yes

No

If so, when?

Give brief information about any previous marriage:

Information about children

Name:

Age:

Education: (in years)

Gender:

Marital Status:

Name:

Age:

Education: (in years)

Gender:

Marital Status:

Name:

Age:

Education: (in years)

Gender:

Marital Status:

Name:

Age:

Education: (in years)

Gender:

Marital Status:

Any other pertinent information regarding children:

Health Information

Rate your health:

Weight changes recently: (+/-)

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

Are you presently taking prescription medication?

Yes

No

What and Why?

Have you used drugs other than for medical purposes?

Yes

No

What and When last used?

Have you ever been convicted of a crime?

Yes

No

Please Explain:

Religious Background

Denominational preference:

Member of: (Church):

How often do you attend per month?

Are you currently in a small group in the church?

Yes

No

What ministry do you serve in at church?

What church did you attend as a child?

Baptized?

Yes

No

Approximate Age:

Religious background of spouse:

Baptized?

Yes

No

Approximate Age:

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?

How often do you pray to God?

Explain recent changes in your religious life, if any:

Personal Information

Other:

Have you ever had counseling before?

Yes

No

If yes, list counselor or therapists and dates:

What was the outcome?

What, if anything, do you fear?

Have you recently suffered a loss from serious relational, social, business, or other reversals, etc?

Yes

No

Explain:

List the people that you hate or are extremely angry with, and the reasons:

Were you ever sexually abused by anyone?

Yes

No

If so, were you abused by:

A relative

A stranger

A neighbor

How old were you at the time?

Was the person who abused you ever prosecuted?

Yes

No

Anything else you would like to share at this time?

Family and Childhood Information

How many older brothers do you have?

How many older sisters do you have?

How many younger brothers do you have?

How many younger sisters do you have?

What number child were you in the birth order?

Check all those who you are on good terms with:

Mother

Father

Brother(s)

Sister(s)

If not, list who you're not on good terms with and why:

Were you raised by anyone other than your parents?

Yes

No

If you were raised by anyone other than your own parents, briefly explain:

Which parent do you feel closest to?

Why

What kind of community did you grow up in?

Urban Area

Suburban Area

Small Town

Rural

City and State of where you grew up?

What was your family's economic situation when you were a child?

What was your happiest memory as a child?

What was your unhappiest memory as a child?

Did you experience a major trauma when you were a child?

Yes

No

Please Explain:

Screen Time

How much time do you spend on a screen (in hours) on an average day that is non-work related?

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

Personal Behavioral Habits

Do you drink coffee or other caffeinated drinks?

Yes

No

If yes, how much per day?

Do you smoke/vape or chew tobacco products?

Yes

No

If yes, how much per day?

Do you use marijuana or other drugs?

Yes

No

If yes, how much?

Occasionally

Often

Very Often

Do you drink alcohol?

Yes

No

If yes, how much?

Occasionally

Often

Very Often

Do you have problems sleeping?

Yes

No

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

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

Do you exercise?

Yes

No

What is your general physical activity level?

Low

Moderate

High

Do you explode when you get angry?

Yes

No

Do you withdraw when angry or hurt?

Yes

No

Do you frequently argue with people?

Yes

No

Of those items checked, which one(s) seems to be the most dominant?

Briefly Answer The Following Questions

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 would help us to help you?

Our available office hours for appointments are Mondays and Fridays from 9:00AM - 5:00PM and Tuesdays, Wednesdays and Thursdays from 9:00AM - 8:00PM. When would you be available for an appointment during those times? (Please put as many availabilities as possible)

(Signed)

(Date)

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