Counseling Request Form Adults

Counseling Request Form

At College Park, we provide biblically-based counseling for children and adults and seek to help those hurting move towards Jesus in the midst of sin and suffering. We would like to learn more about you and what led you to seek counseling by completing this form.

Once this form is submitted a member of the Soul Care Team will reach out to schedule an intake session with a trained biblical counselor. Then our team will offer a recommendation of care that will highlight the ways in which we believe we can best support you during this season through the ministries at College Park Church. This could be through individual counseling, group counseling, or through other means available at College Park such as groups and studies.

We are grateful for the opportunity to serve you in this way.

What is your affiliation with College Park Church?*

Member Regular Attender Attend another church

How do I know if I'm a covenant member of College Park Church? A covenant member of College Park Church is someone who has attended a membership event, signed the member agreement form, and has been voted in by the congregation. A regular attender is someone who attends College Park regularly, has filled out a Connect Card and/or is giving financially to the church by check, credit card, or online giving.

Name

First Name

Last Name

The Soul Care Team is honored that you have chosen to seek care at College Park Church and we wish to help you in any way that we are able.

Due to an increase in counseling requests within our own body and limited resources, we must prioritize care for our members and regular attenders at this time therefore we are only able to offer group counseling for those who are not members/regular attenders at College Park. Visit our group counseling webpage to view the different group counseling options available at College Park Church and learn more about how to apply for the next group.

If you would like to explore other counseling options in the area you can refer to our list of recommended referrals.

If you have any questions please contact us at soulcare@yourchurch.com.

Personal Information

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Birthday*

Age

Gender*

Male Female

Marital Status*

Do you have children?*

Yes No

Education Completed*

Do you work in the Healthcare field or as a caregiver of someone in the Healthcare field?

Yes No

Marriage

Spouse*

First Name

Last Name

Birthday *

Age

Phone*

Email*

Date of Marrige*

Years Married

Is your spouse willing to come for counseling?*

Yes No Uncertain

Are you currently being abused in this marriage?*

Yes No I would like to discuss this

By abuse we mean physical violence, verbal threats, manipulation through guilt, name-calling/put-downs, using Scripture to coerce, using fear to intimidate, isolating from others and other abusive actions.

Health

Rate your current health*

Very Good Good Average Declining

Other:

List any significant illnesses, injuries, or handicaps*

Current medication(s) and dosage*

Have you ever used drugs for anything other than medicinal purposes? If yes, please explain.*

Have you ever had a severe emotional upset? If yes, please explain.*

Have you ever been arrested? If yes, please explain.*

Have you ever seen a psychiatrist or counselor? If yes, please explain.*

Are you willing to sign a release of information form so that your counselor may request social, psychiatric, or other medical records?*

Yes No Not sure

Consent to Counsel

What have you done about the problem?*

What are your expectations from counseling?*

Please read and review the Consent to Counsel Form.

I have reviewed the Consent to Counsel form and agree to its guidelines.*

Yes No

Is there any other information that we should know?*

Please read and review the Facts About Biblical Counseling

Information on this form is viewed as private and will not be shared outside College Park Church unless you authorize consent. If you have any questions regarding this form or College Park Church's counseling policy, please contact soulcare@yourchurch.com

I have reviewed the Facts About Biblical Counseling and agree to its guidelines.*

Yes No

Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ, to be used by him as he helps you to grow in spiritual maturity and prepares you for usefulness in his body.

If you have any questions about these guidelines, please contact soulcare@yourchurch.com

If the guidelines of the consent form are acceptable to you, and you affirm that all the information in this form is correct to the best of your knowledge please sign below.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Save and Resume Later