The Biblical Counseling Personal Data Inventory Today's Date *Birthday *Name *Age *Address *Cell Phone *Email Address *Place of EmploymentMarital Stauts *MarriedSingleMarriedEngagedSex *FemaleFemaleMaleWho referred you? *Have you ever been arrested? *YesNoIf you have been arrested please explain: please state the circumstances below. We want to make sure that any serious incidents in your past have been dealt with in a biblical manner.EducationMarriageSpouse's NameDoes your spouse have a different address?YesNoAddress if differentDate of MarriageSpouse's BirthdaySpouse's AgeWife's Age at MarrigaeHusband's Age at MarriageHow long did you know your spouse before you got married?Length of Dating with Spouse?Length of EngagementHave You Ever Been Separated?YesNoIf yes, then when?Has either of you ever filed for divorce?YesNoIf yes, when?Is your spouse willing to come for counseling?YesNoGive a brief description about any previous marriages.Information about ChildrenChildrenFrom Previous Marriage?YesNoNameAgeLiving?YesNoIf you were raised by anyone other than your parents, briefly explain.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?Have there been any deaths in the family during the last year? If so explain:Health InformationDate of last medical examinationMonthDayYearRate Your Health 1-10 (10 being best)Have you had a recent change in weight? If so how much?List all important present or past illnesses or injuries or handicapsIf the counselor believes that it would be helpful to see your social, psychiatric, or medical reports, would you be willing to sign a release of information form?NoYesAre you presently taking medication? If yes, please list and provide dosage.How many days a week do you get 20 minutes or more of non-work related exercise?How healthfully do you eat? (1-10)Do you have problems sleeping?NoYesHow many hours of sleep do you average each night?Have you ever used drugs for other than medical purposes? ExplainPrevious Counseling ExperienceDatesConselorOutcomePersonality BackgroundHave you ever had a severe emotional upset? (i.e., custody battle, protracted divorce, severe illness, death of a loved one, broken relationship, financial hardship) Explain:Have you ever willfully or been forcibly committed to psychiatric or mental health services? If yes please explain.Indicate any words that describe youHave you ever felt people watching you?YesNoDo people's faces ever seem distorted?YesNoDo you ever have difficulty distinguishing faces?YesNoDo colors ever seem too bright?YesNoAre you sometimes unable to judge distance?YesNoHave you ever had hallucinations?NoYesIs your hearing exceptionally good?YesNoReligious BackgroundChurch NameDenominational PreferencePastor's NamePastor's Phone NumberHow many times per month do you attend worship?How many times per month are you involved in other church related activities?Are you a member of a church?Do you believe in God?Are you saved?YesNoUncertainHow often do you pray?NeverRarelySometimesOftenHow often do you read the Bible?NeverRarelySometimesOftenDo you pray and read the Bible with family?NeverRarelySometimesOftenExplain any recent changes in your religious life.Permission to consult with pastor as deemed helpful by counselor?YesNoHave you worked with your church concerning the issues for which you seek counsel?YesNoExplain the results of those efforts of working with your church or your reasons for not working with your church.Permission to consult with pastor as deemed helpful by counselor?YesNoAdditional QuestionsWhat issue brings you to counseling? *Are you seeking counseling for same-sex sexual desire and/or homosexuality/homosexual behavior?Are you seeking counseling for your minor child?YesNoWhy are you willing to seek help at this time?Is there anything else about your situation that we should know?Consent to Counseling AgreementGoal *Please select an optionAgreeDisagreeThe purpose of biblical counseling is to help you meet the challenges of life in a manner which is pleasing and honoring to the Lord Jesus Christ. Counselees are welcome to make a donation to the counseling ministry; however, this is not a required condition for counseling. You have no obligation, express or implied, to pay fees for the counseling you receive through Jenifer Pepling; however, donations are appreciated and will help ensure that the ministry continues. It costs me approximately $65 for each hour of counseling provided. Biblical Counseling is strictly religious. I believe that the Bible, consisting of the Old and New Testaments, provides thorough guidance and instruction for faith and life (cf. II Timothy 3:16-17, II Peter 1:3-4). My counseling is based solely on the principles of Scripture and does not employ the teachings or methods of modern psychology or psychiatry.Other Professionals, Confidentiality and Conflict Resolution – Arbitration *Please select an optionAgreeDisagreeOther Professional Advice: If you have significant medical, legal, financial, or other technical questions, you should seek the advice of a competent, independent professional. I will cooperate with such advisors and will help you consider their counsel in the light of biblical principles. I urge my counselees to properly care for their physical bodies and to seek medical treatment for all physiological problems. I will assist you in responding to such problems in a godly manner, but my counsel is not intended to replace the services of a qualified physician in the treatment of organic problems. Confidentiality: Confidentiality is an important part of the counseling process. As Biblical Counseling differs in some respects with traditional guidelines regarding confidentiality, I have a policy which specifically addresses this issue. Said policy is attached to, incorporated in, and subject to the other provisions of this Consent to Counseling Agreement. Conflict Resolution – Arbitration: On rare occasions, a conflict may develop between a counselor and a counselee. The Bible commands that Christians make every effort to live in peace and to resolve disputes with each other in private or within the Christian Church (cf. Matthew 18:15-20; 1 Corinthians 6:1-8), without involvement of the secular courts. Therefore, in order to ensure faithfulness to this biblical principle, I require all counselees to agree that any claim or dispute arising under, out of, in connection with, or relating to, the counseling received any dispute with a counselor thereof, shall be settled by biblically-based mediation.Cancellation Policy: *Please select an optionAgreeDisagreeI do ask that you honor your appointments. In the event that you will not be able to make your scheduled appointment, I would appreciate a 24-hour notice. After two cancellations without notification, your time slot may be given to another counselee. My time is valuable and I want to be sure not to waste it. The simple way to avoid this problem is to contact me and change your appointment as soon as you know you will not be able to keep it. Thank you for your cooperation.Confidentiality Policy:click if you agree *Confidentiality is an important and vital aspect of the counseling relationship. To that end, I my representatives agree to carefully guard the information entrusted to us by counselees to the fullestextent possible.I am expected to protect the information I receive in order to ensure the integrity of the counseling process and the privacy of the counselee. Under certain circumstances, however, it may be necessary to reveal information obtained in the counseling process in order to uphold the principles of Scripture and/or the laws of the state of Pennsylvania. A Biblical Counselor does not hold to the legal concepts of the priest/penitent, doctor/ patient, psychotherapist/patient, or counselor/counselee privileges.Situations wherein it may become necessary to reveal otherwise confidential information include, but are not limited to:1. Where a counselee, although encouraged to renounce a particular sin refuses to do so, it may become necessary to seek the assistance of others in the church to encourage repentance and reconciliation in accordance with the Scriptures (cf. Proverbs 15:22, 24:11; Matthew 18:15-20). In said cases, only such information as is necessary to deal with that particular sin will be revealed.Further, said information will only be revealed to those biblically required to be involved. To that end, it may become necessary to contact the pastor and/or other elders of a counselee’s home church.2. Counselors, uncertain as to how a particular issue should be addressed, may reveal necessary information to and seek assistance from another counselor or pastor. Specific names and/or identifying information will be omitted or generalized so as to guard the privacy of the counselee in such circumstances.3. Where a counselee threatens to harm himself/herself or another person, it may become necessary to notify the proper legal authorities, family members, pastor, intended victim, or all of the above. If the counselee makes such threats in the context of a counseling session, the counselor will, upon receiving the information, consult with another counselor, if such is available, who will work with them to assess the situation and assist in making the appropriate notifications, if necessary.4. If a counselor is privy to evidence that abuse or any crime has been or is about to be committed, it may be necessary to reveal such to the legal authorities. This would include but would not be limited to adult and domestic abuse, child abuse, or sexual abuse of any kind.5. The Biblical Counseling recognizes that in the course of the loving discipline of their children, Christian parent may employ corporal punishment, in accordance with the teachings of Scripture and, in conformity with those Scriptures, the Biblical Counseling supports a parent’s right to do so. However, if, in the course of counseling, the counselor comes to believe that a child under 18 years of age has been physically or sexually abused, or by any act or failure to act has suffered non-accidental serious physical injury or non-accidental serious mental injury, or has suffered serious neglect, the counselor will immediately contact the appropriate legal authorities in conformity with PA Act 153. If the counselor is uncertain if a minor child has been abused or neglected (as described above), the counselor will immediately consult with the another counselor or Pastor who will assist in assessing the situation. If in the consultation process it is then suspected that abuse has occurred, the legal authorities will be contacted in conformity with PA Act 153. If the another counselor or pastor are not available for consultation in this second scenario, the Counselor will contact the appropriate legal authorities without employing the above consultation process. When counseling someone who is under familial authority, the counselor may encourage the counselee to inform the familial authorityand/or the counselor may need to inform them.Please be assured that I strongly prefer not to disclose your personal information and will make every effort to resolve a problem as privately as possible. Where appropriate, and when possible, permission to disclose information with necessary parties will be sought from the counselee. Information will only be shared when deemed biblically wise and necessary and when sharing that information is in the counselee’s best interests.Digital SignatureBy typing here you agree that all the above is true.Signature DateSend Message