Personal Data Information Form (Adult)

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?

If Partner Church, which one do you attend?

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

Choose any of the following words which best describe YOU now:

Godly

Ethical

Hypocritical

Strict

Angry

Unreasonable

Abusive

Irresponsible

Cruel

Uneducated

Proud

Embarrassing

Active

Ambitous

Self-confident

Persistant

Nervous

Hardworking

Impatient

Impulsive

Moody

Often-blue

Excitable

Imaginative

Calm

Serious

Easy-going

Shy

Good-natured

Introvert

Extrovert

Likable

Leader

Quiet-boiled

Hard-boiled

Submissive

Lonely

Self-conscious

Sensitive

Humorous

Sloppy

Well-groomed

Self-disciplined

Whiner

Selfish

Lots of friends

Failure

Success

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:

What kind of home did YOU grow up in? (Check all that apply)

Traditional (Father, Mother, Kids)

Authoritarian (Father or Mother made all the rules without discussion. Would not allow for other opinions.)

Divorced

Alcoholic

Drug Affected

Perfectionist (Everything had to be done just right to please)

Critical

Affectionate

Emotional

Repressed Emotions

Religious

Step-family

Abusive

Other

Were you raised by anyone other than your parents?

Yes

No

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

Would you characterize your FATHER as: (Check the appropriate words)

Godly

Ethical

Hypocritical

Strict

Angry

Unreasonable

Abusive

Irresponsible

Cruel

Uneducated

Proud

Embarrassing

Active

Ambitous

Self-confident

Persistant

Nervous

Hardworking

Impatient

Impulsive

Moody

Often-blue

Excitable

Imaginative

Calm

Serious

Easy-going

Shy

Good-natured

Introvert

Extrovert

Likable

Leader

Quiet-boiled

Hard-boiled

Submissive

Lonely

Self-conscious

Sensitive

Humorous

Sloppy

Well-groomed

Self-disciplined

Whiner

Selfish

Lots of friends

Failure

Success

Would you characterize your MOTHER as: (Check the appropriate words)

Godly

Ethical

Hypocritical

Strict

Angry

Unreasonable

Abusive

Irresponsible

Cruel

Uneducated

Proud

Embarrassing

Active

Ambitous

Self-confident

Persistant

Nervous

Hardworking

Impatient

Impulsive

Moody

Often-blue

Excitable

Imaginative

Calm

Serious

Easy-going

Shy

Good-natured

Introvert

Extrovert

Likable

Leader

Quiet-boiled

Hard-boiled

Submissive

Lonely

Self-conscious

Sensitive

Humorous

Sloppy

Well-groomed

Self-disciplined

Whiner

Selfish

Lots of friends

Failure

Success

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

Problem Check List: (Check those which are current)

Angry

Envy

Appetite

Anxiety

Fear

Memory

Apathy

Gluttony

Moodiness

Bitterness

Guilt

Rebellion

Change in Lifestyle

Health

Sex

Children

Homosexuality

Sleep

Depression

Impotence

Abuse

Deception

In-laws

A Vice

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)

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 define 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, 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.

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 behavioral 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 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(), have read, fully understand, and agree to the conditions of this Informed Consent And Counseling Agreement that by signing below.

(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.