Counseling Application
  • Please take the time to answer these questions.

    The information you provide will help us help you.
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    Today's Date:
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    First and Last Name
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    Home Street Address
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    Zip Code
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    Home Phone
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    Mobile Phone (if none answer NA)
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    email (if none answer NA)
  • age
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    Were you referred to Mill Creek's counseling ministry by someone?
  • If you were referred, who told you about our ministry?
  • Which day of the week and which time of day is the best for you to meet with a counselor?

    Please tell us a little about your background.
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    Education (please check all that apply)
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    Is your father still living?
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    Father's Name
  • Father's Age
  • Father's Marital Status
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    Describe your relationship with your father.
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    Is your mother still living?
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    Mother's Name
  • Mother's Age
  • Mother's Marital Status
  • Describe your relationship with your mother.
  • Were you raised in a home with step parents? If so, please describe that relationship?

    Please fill out if you were ever under the legal guardianship of anyone other than your parents.
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    Growing up, were you ever under the care of a legal guardian?
  • Name of legal guardian
  • Relationship of guardian to you
  • Reason for guardianship
  • Approximate dates of guardianship

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    Describe your childhood.
  • Were any of these things a part of your childhood? (check all that apply)
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    Please describe any of the areas you may have checked. If none, answer NA.

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    What is your marital status?

    If you are currently not married, please fill out this section.
  • Are you currently in a relationship with someone?
  • If you are single & in a relationship...

  • How long has this relationship existed?
  • Briefly describe your relationship.

    Please fill out this section if you are currently married.
  • Number of marriages for you:
  • Spouse's Name
  • Spouse's Occupation
  • Spouse's Religious Background:
  • Number of Marriages for Spouse:
  • Spouse's Education
  • Will your spouse come to counseling?
  • Is your spouse agreeable with you coming to counseling?
  • If no to either of the two previous questions, please explain why this is the case.
  • Wedding Anniversary
  • Have you been separated or are you currently separated from your spouse?
  • If yes to the previous question, what were the dates and reason for the separation?
  • Children's Names and ages. If no children, answer NA

  • What is your occupation?
  • Is there anything about your job that causes you dissatisfaction? If so, please explain.
  • Business Name
  • Business Address
  • Business Phone
  • List a brief history of employment. Include company name, position, and approximate employment dates:

  • Denominational Preference
  • Current church:
  • Address of Current Church
  • Pastor's Name
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    Do you believe in God?
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    Do you pray?
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    Would you say you are a Christian?
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    Would you say you are in the process of becoming a Christian?
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    Have you been baptized?
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    Do you consider yourself saved?
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    How would you define the term "Christian"?
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    Was your family religious during your childhood? Briefly describe.
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    List any significant religious experiences such as confirmations, baptisms, etc.

    This information is voluntary. All information on this form is considered confidential unless your life or the life of another is at stake.
  • Do you have any current medical condition(s)? If so, please explain.
  • Have you ever been given a mental health or psychological diagnosis? If so, please explain.
  • Are you currently experiencing any unusual physical symptoms (such as lack of sleep, physical pain, heart palpitations, etc) for which you have not seen a doctor? If so, briefly describe.
  • Physician's Name, office phone, and address.
  • Please list any medications you are taking AND WHAT THE MEDICATION IS TREATING.
  • About how much caffeine do you consume each day?
  • Are you a smoker?
  • Approximate date of last physical examination
  • About how much sleep do you average each night?
  • Is this sleep restful?
  • Have there been any recent changes in your sleeping pattern?
  • Have you noticed any changes in your personality (such as increased anxiety, irritability, anger, etc)? If so, please describe.
  • Do you drink alcoholic beverages? If so, indicate how frequently and how much.

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    Are you seeking assistance for any of these things? Please check all that apply.
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    For each category checked above, in two or three sentences please describe how this is a problem for you.
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    Are there any other issues we should talk about?
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    Have you ever been arrested? If so, please describe.
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    Have you ever used drugs for anything other than medical purposes? If so, please describe.
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    State in your own words your reason for coming for counseling.
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    When did the problem begin? Specify as clearly as you can remember.
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    Please describe any significant events occurring at that time.
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    What have you done to try and resolve this?
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    In what ways have you contributed to the problem?
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    What would you like us to do? What kind of help do you hope you can receive?
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    Is there any other information we need to know?
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    From whom have you sought help for this problem? Check all that apply.

    Dear Friend,

    This application is designed to encourage you as you diligently study and apply the Lord’s counsel. First we want you to know that we are committed to serve the Lord as your counselors, by letting Him rule over our thoughts, words, and actions. If at anytime you feel a counselor is not reflecting the character of Christ (facial expressions, tone of voice, choice of words, etc.), we encourage you to share your concern to the counselor first, and then if necessary to the pastor overseeing counseling at Mill Creek Community Church.

    Session discussions are confidential unless 1) life threatening information is revealed, 2) situations are revealed that require us to report to civil authorities, or 3) serious sins requiring accountability to church leaders (Matt 18:15-17) occur. If such a requirement develops, we will discuss the need with you.

    Biblical Counseling involves the study and diligent application of life principles (truths) that are revealed by God through Scripture. Many today study hard to earn the educational degrees necessary to get a good job and provide for their physical needs. Unfortunately, very few apply the same time and effort to build Christ-centered relationships, that please and honor the Lord. For counseling to “work”, you must make this process top priority and demonstrate such a commitment by your daily actions. You are responsible for how you implement counseling advice as your own personal choice and responsibility. Thus, we ask that you prayerfully commit to invest the time and hard work that is worthy of Christ who died for you.
  • Please bring the following with you to each session:

    A Bible
    Any past homework assignment
    a means to take notes

    Please read the following paragraphs very carefully. You must sign at the bottom, testifying to your agreement, in order to be considered for counseling.

    I understand that I will be receiving biblically-directed counseling. The acceptance of this application and any counseling or continuation thereof shall be at the counselor’s discretion. I understand that the counselor, although supervised clergy, is not a licensed therapist and will be providing spiritual and biblical counseling. The counselor is obligated by state law to report any violations of the law. The counselor may refer the counselee to licensed medical or mental health professionals if, in his or her judgment, such referral is necessary. The counselor may consult with a member of the Mill Creek pastoral staff responsible for the counseling ministry for accountability or guidance as they deem necessary. Such consultation may occur if there are serious statements of self-harm or violence, any suspected involved in the occult, severe emotional trauma, or in cases of physical or sexual abuse.

    We believe that accountability within the church and corporate worship with the church are crucial experiences for all Christians. For that reason, we generally require ALL those receiving counseling at Mill Creek to attend on Sundays at Mill Creek during the course of their counseling. Our services are held at 7825 Gleason at 8:45am and 10:30am. Your counselor will expect to hear back from you on attendance of our worship services. Some homework assignments given during the course of counseling may be related to worship service attendance.

    Failure to complete assignments given in counseling sessions may result in the suspension of further counseling. I recognize that I may, as the counselee, terminate counseling at any time, and agree not to seek any legal recourse against the counselor. I also authorize the counselor to record sessions with the understanding that such recordings are confidential between the counselor and counselee. Such recordings may include electronic, audio, or written notations.

    All notes, information and data collected by the counselor remain the property of the counselor until such time that they are destroyed by the counselor at his/her discretion. Notes and information collected by the counselor are not for the purposes of diagnosing any medical or psychiatric conditions or establishing any legal proofs. Information collected by the counselor is for the primary purpose of understanding issues of the counselee in order to aid in the formulation of related homework.
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    By clicking on the following choice I either 1) agree to counseling via electronic signature by answering YES or 2) do not agree to counseling by answering NO.
  • By typing my name below, I agree to an electronic signature consenting to counseling with a Mill Creek Community Church counselor.

That's all, folks!

* End page and disqualification logic can only be seen in the live survey