Pre-Engagement/Pre-Marital PDI Form 2023

About the Ministry

The Pastoral Care Ministry of The Chapel offers counseling to provide pre-marital, pre-engagement, or marriage biblical counseling. This is offered as a ministry to those who call The Chapel home and is offered on a short-term basis.

Each person must complete a PDI form.

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.

Your request will be reviewed and addressed as quickly as possible. However, please be patient as our ministry currently has a waiting list for those who are waiting to be paired with a biblical counselor. We are grateful that many people are seeking help, but the number of requests has grown beyond the number of biblical counselors available at the moment. Please be patient with us as we are doing are best to meet the needs as soon as possible.

Confidentiality

All communications, records, and contacts 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 dependant 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 counselee. 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.

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

Personal Information

First Name:

Last Name:

Address:

City:

Zip Code:

Occupation:

Place of Employment:

Phone (C):

Phone (H):

Phone (W):

Email:

Gender:

Male

Female

Birthdate:

Age:

Boyfriend/Girlfriend/Fiances Name:

What type of Counseling are you seeking?

Pre-Engagement

Pre-Marital

If Pre-Marital, do you have a date set?

Yes

No

If yes, what is the date?

Pastor performing the ceremony is?

Referred to The Chapel By:

Relationship Information

How long did you know each other before dating?

What is the length of steady dating?

What is the length of engagement, if engaged?

Have you ever been married before?

Yes

No

If so, when?

How long?

How did the marriage ended?

Death of Spouse

Divorce

Do you have children?

Yes

No

What is/are the child's/children's age(s)?

Any other helpful information:

Health Information

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

Gained Weight

Lost Weight

List any important illnesses, injuries or handicaps that you may have:

Are you presently taking any prescription medications?

Yes

No

If yes, what?

If yes, why?

Have you ever used drugs other than for medical purposes?

Yes

No

If yes, what?

When last used?

Have you ever been convicted of a crime?

Yes

No

If yes, please explain:

Church Activity

If you attend The Chapel, which Campus do you regularly attend?

CrossPoint

Lockport

Cheektowaga

Niagara Falls

How long have you been attending The Chapel?

Do you attend a Partner Church?

Yes

No

Which church?

Do you serve in the church that you attend?

Yes

No

In what capacity do you serve?

Have you been baptized as a believer?

Yes

No

If you have been baptized, approximatly at what age were you?

Are you currently involved in a small group?

Yes

No

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 religious life, if any:

Personal Information

Have you ever had counseling before?

Yes

No

If yes, list counselors or therapists and dates:

What was the outcome?

What if anything, do you fear?

Have you recently suffered a loss from a serious relationship, social, business, or any other loss?

Yes

No

If yes, please name it and explain:

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

Where 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 younger brothers do you have?

How many older sisters do you have?

How many younger sisters do you have?

Are you on good terms with your Mother, Father, Siblings? If not list who your not on good terms with and briefly why:

Which number are you in the birth order?

If you were raised by anyone other than your biological parents, please explain:

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 closer 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 families 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? (ex. at home, at school, at a neighbor's home, at a relatives home)

Yes

No

Please Explain:

Screen Time

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

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 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 often?

Never

Occationally

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 or hurt?

Yes

No

Do you withdraw when you get angry or hurt?

Yes

No

Do you frequently argue with people?

Yes

No

Which one(s) of the above seem to be most dominant?

Briefly Answer the Following Questions

In addition to pre-engagement or pre-marrital counseling are there any issues that we may help you with?

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

What do you hope to accomplish with our help?

Is there any other information that we should know that will help us 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. 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.