Helpful Forms for Ministry Use
We share the following forms as examples, not as legal advice. Biblical Counseling Ministries assumes no
responsibility for the use or adaptation of these forms. We encourage you to receive competent legal
counsel to determine if these forms comply with the laws that apply to you.
For a Personal Data Inventory form (PDI) that may be adapted to meet your needs, consult the
appendices in Competent to Counsel by Jay Adams (Grand Rapids: Zondervan, 1970), 171-174.
BCM organizational documents are available only by application and approval of the BCM board of
directors. Some restrictions apply. Call our home office (715-423-7190 weekdays 9-12 and 1-4) or email
BCM at [email protected] for more information.
Copyright 2012 Day One Publications. Used by permission. These forms may be reproduced and adapted
for use in good faith in a biblical counseling ministry. For more information about organizing a well-run
counseling ministry, we urge you to read Building a Church Counseling Ministry Without Killing the
Pastor by Sue Nicewander, with Pastor Jon Jenks, Pastor Stephen Steinmetz, and the BCM Board of
Directors, published by Day One Publications, 2012.
FIRST CONTACT TELEPHONE INFORMATION FORM
Name: ________________________________________
Date: ___________________
Source of referral: _____________________________________________________________
Phone # ___________________________ Address: _________________________________
Work # ___________________________
_________________________________
Home Church _________________________________________________________________
Description of Problem (s)
Attempted Solutions
Result of this Contact
FIRST CONTACT TELEPHONE INFORMATION FORM
Name: ________________________________________
Date: ___________________
Source of referral: _____________________________________________________________
Phone # ___________________________ Address: _________________________________
Work # ___________________________
_________________________________
Home Church _________________________________________________________________
Description of Problem (s)
Attempted Solutions
TO REFERRING PASTOR
Before giving this intake form (PDI) to your referred counselee:
Please sign and date the PDI form on the line labeled “Referring Pastor’s Signature” (top of page
1). Please sign and date the enclosed confidential envelope also.
Requested donation for counseling is _____ per 50-minute session. Please discuss with your
referred counselee how payment will be made. We suggest that the referring church consider
helping counselees who are in financial need. Payments must be brought to sessions unless a
monthly invoice is requested on this form. Invoices are sent to the referring church. Any other
arrangements must be made in advance with the counselor.
You or your counselee should return this completed referral form to our home office at the above
address. Once the completed PDI and this referral form have been received in our home office, an
appointment may be made.
Thank you for allowing us to assist you! We look forward to serving you.
Please print legibly
Counselee Name: ______________________________________________________________________
Referring Pastor: Print _____________________________ Signature ____________________________
Church Name and Address: ______________________________________________________________
_____________________________________________________________________________________
Church Phone (or Pastor’s Phone): ________________________
Email: _____________________________
Counselee will pay in full at each session.
Counselee will pay in part for each session in the amount of $______. Balance of $_______ will be
paid by referring church. Please have counselee bring payment to each session, unless other
arrangements are made in advance with counselor.
Church will pay in full for _____ sessions on a per-session basis.
Church will pay in full for sessions on a monthly basis. Please send invoice to (if different from
above church address):
Other. Any other options must be approved by the counselor prior to first appointment. Please call
our home office for assistance. Phone: _____________________________
COUNSELEE INSTRUCTIONS
Welcome! In order to best serve you, we will need some preliminary information. The attached Personal
Data Inventory form (PDI, our intake form) will give us background that will save us time in sessions and
help your counselor to better understand your concerns. Please fill it out carefully. Read this sheet for
instructions on returning your PDI and preparing for your first session. We look forward to working with
you.
1. We offer counseling only by pastoral referral. If you do not have a referring pastor,
you may contact one of the pastors at our home office for assistance: ___________
_________________________________________________________________
Ask your referring pastor to sign and date the top of the attached PDI form and the
front of the confidential envelope if he has not already done so. He will also need to
fill out the pastor’s referral form he received with the PDI. He may send that
separately, or you may include it with your completed PDI form.
2. Fill out this PDI form completely and sign the Terms of Counseling. This must be
done before an appointment will be made.
3. The completed PDI should be sealed in an envelope and marked ‘confidential.’ The
PDI envelope will not be opened by the secretary. Write your name on the outside
of the envelope and have your pastor sign and date it. Then insert it into a larger
envelope that can be addressed and stamped for mailing.
4. Mail or hand carry the PDI in the envelopes to:
5. Allow sufficient time for the PDI to be received by our office. Then you may call
_____________ or come in to make an appointment preferably within two weeks.
You may be asked to provide your name, address, and other basic information to
the secretary when the appointment is made.
6. Requested donation for counseling is $_____ per 50-minute session. If you are
unable to cover the cost of the counseling, please contact your referring pastor for
help. Please bring payment to each session. Checks may be made out to
_______________________________.
7. Bring your Bible, a pen, and a notebook to each session. We look forward to
meeting you soon!
COUNSELING INFORMATION
1. Diagnostic Tools. We use helpful counseling forms such as this intake form, homework journals, and other aids
to gain an understanding of the central problems a person is experiencing.
2. Intent Listening. We encourage the counselee to speak his or her mind in an appropriate fashion and to discuss
thoughts, anxieties, resentments, and fears so that the counselor will have a clear understanding of the central
problems.
3. Team Counseling. There are times when a counseling situation may call for a team approach. If this is the
case, we may have more than one counselor involved in a session. The counselors share insights and opinions
with one another which pertain to the case. Team counseling can be especially helpful in marital counseling.
4. Assignments. Counselees make more rapid progress when they are required to study or to perform specific
information-gathering or behavioral assignments which pertain to the problem. We tailor these assignments to
the individual counselee and the circumstances.
5. Accountability. We are not interested in wasting the time of the counselors or the counselees. We are interested
in believers learning how to experience the peace and joy that result from a walk of obedience to God’s Word,
and we hold the counselees accountable for doing the assignments on schedule.
How Long Does Counseling Take?
Each counseling session lasts for 50 minutes. Time required to complete biblical counseling will vary according to
the individual, his or her motivation, and the particular problem. On the average, however, biblical counseling
requires far less time than conventional secular counseling. Very simple problems are often solved in one session.
Severe problems may require a longer period. Marital counseling may require as many as twelve to eighteen
sessions or more. Substance abuse problems may require many more sessions, with intense accountability and
follow-up.
How Much Does It Cost?
We ask for a ___________ donation per 50-minute counseling session. Your referring church may agree to help
you with counseling up to a designated number of sessions. Please discuss this possibility with the pastor who
referred you.
About Confidentiality
We are careful to protect each counselee’s confidentiality within biblical guidelines. There are times, however,
when a counselor must consult with other counselors for advice. If information is revealed in counseling which
indicates a genuine potential for harm to you or to others, the counselor may have to share that information with the
appropriate authorities or family members. If the counselor has a supervisor, reports will be made to that
supervisor, with the minimum necessary information revealed and with your identity being concealed if possible.
See “Terms of Counseling” for more complete information concerning confidentiality.
TERMS OF COUNSELING
Reviewed with Counselee:__________________
Date and Counselor Initials
Our goal in providing Christian counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to fully enjoy His love for you and His plans for your life. We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of secular psychology or psychiatry. Neither the pastoral nor the lay counselors in this ministry are trained as psychotherapists or mental health professionals, nor should they be expected to follow the methods of such specialists. If you have specific legal, financial, medical, or other technical questions, you should seek advice from an independent professional. Our pastoral and lay counselors will help you to consider their counsel in light of relevant scriptural principles.
This counseling ministry is a non-profit, short term, biblically-counseling, peer-supported program of seminary-trained lay counselor(s) who are supervised by pastoral counselors, available to help members and friends of its home and host churches. We take a biblical approach to counseling. All problems will be addressed from principles and directives found in the Bible, unless the problem is organic. A counselee with an organic problem will be encouraged to seek medical assistance. This ministry is not a medical facility and is not equipped to treat organic problems. The counselor will make an effort to work alongside medical professionals on biological concerns. Information released to a medical professional would be provided only by prior written consent from the counselee unless that counselee’s life or the lives of others are endangered.
Due to scheduled appointments, your counselor will not normally be available for telephone conversations during the week. If you have an emergency, please call to talk with the secretary. If she cannot help you, the counselor will return your call as soon as possible. Please seek appropriate protection if you are in danger and unable to reach your counselor immediately.
Fees and Donations
Fees are required for seminars and workshops, and may be charged for various literary materials the counselor believes are important to the counseling process. In order to help meet our costs, a $_______ donation is requested at the completion of each counseling session. This form serves to provide the counselee with reasonable notification of donations requested. Please make checks out to ______________________________. If you are unable to donate this amount, please discuss this in advance with your referring pastor. We also welcome gifts to the counseling ministry. All donations that are not for counseling sessions or materials are tax deductible. These donations need to be in cash or given in a separate check apart from the counseling session donation.
Supervision
To meet our objective of providing the highest level of care possible, all lay counselors are supervised by the executive director. Counselor notes may be reviewed periodically by the Executive Director or by the senior pastor of the home church to ensure sound biblical principles and counseling methods, and to comply with your church’s discipline process. Lay counselors will refer any counselee in a suicidal condition to the referring pastor and the counselee’s family or to the proper authorities. Lay counselors will report incidents of “reasonable suspected” child abuse, domestic violence, threats on life, or subpoenas to the appropriate authorities as required by law. The Executive Director or supervising pastor will review mediation agreements administered by counselors. Counselors are to report any incident worthy of church discipline to the Executive Director, who will cooperate with your church’s discipline process on behalf of the counselor. The counselor may seek legal advice with regard to confidential information without counselee consent.
Confidentiality
Confidentiality is biblically guarded at all times. Certain laws require that counselors warn the appropriate individuals if the counselee intends to take harmful, dangerous, or criminal action. Counselors are also mandated to report any incidence of “reasonably suspected” child abuse (physical or sexual) and elderly abuse, or domestic violence to the appropriate authorities per the Supervision section above. Members of referring churches who reveal behavior worthy of church discipline, such as divorce without biblical basis, adultery, abuse of others, unethical or illegal practices, are subject to referral to the church disciplinary process by way of the executive director. If you are a member of a church, you have the prerogative of including your pastor in the counseling process, recognizing that this may limit the value of any privileged communication. Lay and pastoral counselors are not permitted to breach confidentiality to church discipline committees, or any other party except as provided in the Supervision section in this Terms of Counseling form, or by written permission from the counselee. The counselee has a right to access his or her records and written information from those records in accordance with state and federal statutes.
Insurance
This ministry has no authorization for coverage with any insurance company or medical organization. Should a company offer to pay the requested donation for counseling, the payment will be accepted. All requested donations will be paid for by the counselee unless a church or other party chooses to pay. All counselees will be given a two-week notice of any change in requested donation.
Other counseling services are available in the community and the counselee has a right to freely choose among them, and to change practitioners after counseling has begun, within the limits of health insurance, medical assistance, or other health programs when there will be a change in the provider of counseling. We will provide information about other sources of counseling available and the counselee has a right to a coordinated transfer when there is a change. These rights can be exercised without retaliation by our ministry.
Terms of Counseling, page 2 Waiver of Liability
The undersigned, seeking biblical counseling as such as adhered to by our ministry, a non-profit religious organization, hereby acknowledges his or her understanding of the following conditions and further releases this ministry, its agents, counselors, and employees, from any liability or claim arising from the undersigned’s participation in the above-mentioned biblical counseling program:
1. It is understood by the participant counselee that all biblical counseling will be provided by supervised counselors who counsel based upon their understanding of Scripture, not as licensed therapists;
2. That all counseling provided in the biblical counseling program is provided in accordance with the biblical principles adhered to by this ministry and are not necessarily provided in adherence to any local or national psychological or psychiatric association; 3. That no representation has been made, either expressly or implied, that the biblical counseling, as conducted by the
above-mentioned lay counselors, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions.
4. Certain statements may not be protected as privileged communications under law.
I, ____________________________________, affirm the accuracy of the personal information provided herein, and have read the (Name)
information above and agree to the conditions set forth therein.
I agree and understand that all counseling that I receive from ____________________________________ will be based on the counselor’s understanding of the Bible and its practical application. I am consenting to receive counseling from this ministry with full knowledge that biblical counselors believe and teach the authority of the Scriptures.
I hereby agree to the following conditions:
I am committed to resolving my problems by coming into obedience to the Word of God. I will do the assigned weekly homework or the session will not be held.
I will attend church each Sunday while I am in counseling.
I understand that confidentiality cannot be absolutely guaranteed under the conditions indicated above. I will keep my financial responsibilities current.
I will keep the appointment time, or will call to cancel or reschedule at least 48 hours in advance, with a legitimate reason. Three cancellations without prior notice will forfeit future sessions.
I will pay a $20.00 fee if I cancel without a 24-hour notice.
If I am unhappy in any way with the counseling, I will first discuss it with my counselor, then with my counselor and his or her supervisor, and then appeal it to the Board of Directors of this ministry. I agree to enter Christian mediation if I cannot solve my grievance, or, if necessary, a legally binding arbitration in accordance with the Rules of Procedure of the Institute of Christian Conciliation; judgment upon an arbitration award may be entered in any court having jurisdiction.
I agree not to subpoena session notes for any reason.
Sessions may be terminated at any time by the counselee or counselor.
Having clarified the principles and policies of our ministry, we welcome the opportunity to minister to you in the name of Christ and 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 talk with the receptionist or one of our counselors. If these guidelines are acceptable to you, please sign below.
_________________________________________ _________________ Counselee Date __________________________________________ __________________ Counselee Date __________________________________________ _________________ Counselee Date __________________________________________ _________________ Counselor Date
COUNSELEE CONSENT FOR RELEASE OF INFORMATION
1I, ______________________________, hereby authorize and consent to allow the herein designated individual(s)
to release personal information gained through our counseling sessions to the individual(s) and/or organization(s)
named below.
Individual(s) who may exchange information about me:
1. __________________________________________
2. __________________________________________
Specific information not to be released: (Check here if no restrictions
).
1. __________________________________________
2. __________________________________________
The purpose for this release is for biblical counseling at __________________________ Church.
I understand that I have no obligation to disclose this requested information and may revoke this consent at any
time by informing any and all individuals or organizations listed above.
I waive, on behalf of myself and any persons who may have an interest in this matter, all provisions of the law
relating to the disclosure of any confidential information and release ___________________________________
______________________________ and its counselors from all legal responsibility or liability that may arise from
this authorization.
___________________________________
______________
Counselee
Date
___________________________________
______________
Legal Guardian
Date
____________________________________
_____________
Witness
Date
1 Adapted from Howard Eyrich, Christian Counseling Center Management: A Management Case Study Approach (Growth
