Premarital Counseling Application
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  • 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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    City
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    State
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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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    gender
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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?
  • PERSONAL HISTORY

    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.
  • GUARDIANSHIP

    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
  • CHILDHOOD EXPERIENCES

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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.
  • Relationship

  • How long has this relationship existed?
  • Give a brief description of how you met and have dated:
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    Relationship Status (please check all that apply)
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    Which of the following best describes your relationship (check all that apply):
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    How long have you known each other?
  • We see each other...
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    Why do you want to get married?
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    What strong point does he/she bring to your relationship?
  • Have you set a wedding date? If so what is it. If not, you may skip this question.
  • PREVIOUSLY MARRIED PERSON

    Please fill out this section if you were previously married.
  • Number of marriages for you:
  • Reason for dissolution of previous marriage:
  • Children's Names and ages. In no children, answer NA
  • OCCUPATION

  • 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:
  • RELIGIOUS BACKGROUND

  • 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.
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    Why do you want to be married by a pastor at Mill Creek?
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    Which of the following topics would you like to discuss in premarital counseling? (please check all that apply)
  • Is there anything else you would like us to talk about?
  • COUNSELING GUIDELINES

    We are glad that you have chosen Mill Creek’s Discipleship & Counseling Center for your premarital counseling. We believe that you will come to see this experience as one of the best investments you are making together for the long-term greatness of your marriage! following information will give you a general idea of what to expect from premarital counseling.
  • Commitment.

    Marriage is a commitment, and premarital counseling is a commitment that will help your marriage begin strong. It is a time commitment. Generally your counselor will want to meet with you regularly (weekly if possible) so that you can make progress in your commitment. You will be utilizing a biblically based Christian premarital curriculum meant to anchor your home solidly on good spiritual foundations. You will be asked to work on some assignments regarding communication and mutual spiritual commitments during the week between sessions. This is the key to solid counseling. It helps for you to begin to apply what we will be learning together. This will take time and effort from all parties. It is best to make time for this throughout the week as well as your weekly appointment with the counselor(s).
  • Curriculum.

    A pre-marriage book with built in discussion questions will be provided for you as part of the program. In addition, we ask that you bring a bible with you to each session, along with a means to take notes. It will be helpful for your interactions with counseling staff as well as for take home assignments.
  • Cost & Overview.

    We ask for a donation of $275 per couple to cover the entire cost of the premarital counseling program. This includes the cost of all materials. We like to set up 12 one hour sessions, but can meet with you either 8 or 6 sessions if you don’t mind meeting longer than one hour per time. In addition, a post-marriage followup appointment is part of the program. Our normal suggested donation is $45 per session for counseling at our center, so we want to offer engaged couples a break with the pricing for this program. Checks can be made out to Mill Creek Community Church, or your counselor can give you details on how to make and online donation at www.mymillcreek.com/donate. To request financial assistance contact the Center Director at the contact information furnished in the next section.
  • Cancellation Policy & Counseling Center Contacts

    We offer counseling services to our church and our community and in order to effectively do so, it is very important that counseling appointments be made and kept. Your counselor will work with you to do their best to meet at a time convenient for you. Sometimes events may require a cancellation or rescheduling.

    Appointments must be cancelled 24 hours prior to your scheduled time. Please contact your counselor directly via email, text, or phone message to cancel. They will provide this to you. A pattern of poor communication on appointment cancellations may result in suspension of further counseling.

    We never want money to be a problem preventing good counsel. If this would present a financial hardship to you, please feel free to contact the center director to arrange a counseling scholarship. If for any reason you would like to speak with the director of the Mill Creek Discipleship & Counseling Center, please contact:
    Martin Burch, Pastor of Discipleship
    Mill Creek Community Church
    Phone or text: 913-667-9812
    Email: mburch@mymillcreek.com
  • What to expect at a counseling session.

    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 of Discipleship at Mill Creek Community Church.

    Session discussions are confidential unless life threatening information, requirements by law or serious restoration requirements (Matt 18:15-17) arises. If such a requirement develops, we will discuss the need with you first.

    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. 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 to each session:

    A humble, teachable attitude.
    Your Bible.
    All materials given by your counselor.
    Your completed homework, which was assigned the previous session.
  • COUNSELING AGREEMENT

    Please read the following paragraph 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. 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.

    I agree to pay the $275 fee for premarital counseling.
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    By clicking on the following choice I either 1) agree to premarital counseling via electronic signature by answering YES or 2) do not agree to premarital counseling by answering NO.
  • By typing my name below, I agree to an electronic signature consenting to counseling at Mill Creek Community Church's Discipleship & Counseling Center.

That's all, folks!

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

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