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BIBLICAL COUNSELING MINISTRY

Welcome to Grace Biblical Counseling Ministry


Dear Friend,
Welcome to Grace Biblical Counseling Ministry (GBCM). We are grateful that you have welcomed us into your
life at this time. It is never easy to ask for help. We admire the courage, faith, and humility this first step
represents on your part. It is our prayer that God will bless this step and use our time together to build more
hope and direction into your life.
Our goal at GBCM is to provide the highest quality, Christ-centered counseling to individuals and families who
are hurting or confused. This means that we will look through the prism of Scripture to see how your beliefs,
values, and priorities are contributing to your struggle, whether it be in your emotions, relationships, or sense
of identity. We have found this to be the greatest source of authentic, consistent hope.
The next step in the counseling process is to complete the intake forms you are now reading. We have
designed them to allow the counseling process to start smoothly. You will need to allow approximately 45
minutes to complete these forms.
The counseling forms are designed to (1) help us to get to know you in a comprehensive, holistic, and efficient
manner and (2) help you organize your thoughts about your counseling objectives.

The following five pages provide your counselor with background on your situation (if you are married,
then you and your spouse will both need to complete a set of these forms).

Finally, the last three pages contain the policies of GBCM. Please read, initial, and sign these pages. If
you have any questions, your counselor will be happy to answer them. Thank you for taking the time
to complete these forms.

Childcare is not provided, and children are not allowed to sit unattended in the waiting room. If you
are unable to make alternative plans for your child for the first appointment and subsequent
appointments, then counseling should be postponed until arrangements can be made.

Please arrange to be on time to maximize your benefit from counseling.

NOTE CONCERNING MEDICATION: If you are taking any prescription medication(s) please do not alter your
dose on the day of your appointment. If you have recently begun a new medication, please allow
approximately two weeks before scheduling your appointment.
NEXT STEP: Your next step is to thoughtfully complete these forms and then either email the forms back to
secretary@gracebaptistchurch.info, fax them to 636-724-3710, or mail them to our church office (3601
Ehlmann Rd., St. Charles, MO 63301). Once we have received your forms, we will contact you to schedule
your first session.
We are grateful to be able to serve you at this time and to be a part of the journey God has for you. We look
forward with a sober anticipation toward playing a role in your progress and hope.
In Christ,

Jonathan Krawczyk
Director of GBCM
Grace Biblical Counseling Ministry

PERSONAL INFORMATION
Date: _________________________
Name: ______________________________________________________

Gender: Male Female Age: ________

Address: ___________________________________________ City/State: _______________________ Zip : __________


Primary Phone Number(s): _______________________________________ May we leave a message here: Yes No
Secondary Phone Number(s): ____________________________________

May we leave a message here: Yes No

Occupation/Employer: ____________________________________________
Birth Date: ______ / ______ / _________

Avg. Hours/Week: __________________

Email Address: __________________________________________________

Highest degree(s) earned: ___________________________________________ School:___________________________


With Whom Do You Currently Live: (Please check all that apply)
Alone

Parent(s)

Spouse

Children

Boyfriend

Girlfriend

Other: __________________

Marriage & Family Information: (Please complete if you are married or currently engaged)
Name of Spouse (or Fianc/Fiance): ___________________________________________________ Age: ___________
Address: ( same as above) ___________________________________________________________________________
Phone #: ( ____ ) ______ - ____________ Email Address: _________________________________________________
Occupation/Employer:_____________________________________________ Avg. Hours/Week: _________________
Highest degree(s) earned: ___________________________________________ School:__________________________
Is spouse willing to come for counseling? Yes No Uncertain
Have you ever been separated? Yes No Currently When/How Long? ____________________________________
Date of Marriage: ____________________________ Your ages when married: Husband _________ Wife __________
How long did you know your spouse before marriage? ______________________________________________________
Length of steady dating: ____________________________ Length of engagement: ______________________________
Give brief information* about any previous marriages:
Ex-Spouse's
Name

Year
Married

Length of
Marriage

Reason for Divorce

# Kids

* Other relevant information can be written on the back of this page.


Childs Name

Age

Gender

Living

At Home

Married

M/F
M/F
M/F
M/F
M/F

Y/N
Y/N
Y/N
Y/N
Y/N

Y/N
Y/N
Y/N
Y/N
Y/N

Y/N
Y/N
Y/N
Y/N
Y/N

Special Condition(s)

PM/A/MC*

* Check this column if child is by previous marriage (PM), adoption (A), or lost to miscarriage (MC).

Grace Biblical Counseling Ministry

SPIRITUAL / RELIGIOUS INFORMATION


Do you consider yourself a religious person?

Yes No

Church Name: ____________________________________________________ Number of years at church: __________


Pastors Name: _____________________________________________________________________________________
Permission to consult with pastor as deemed helpful by counselor?

Yes No

Denominational preference: ___________________________________ Church attendance: _______ (times per month)


Are you a part of a Sunday School class?

Yes No

Are you a part of a Small Group?

Yes No

What are you learning through sermons and Bible studies at your church? _____________________________________
__________________________________________________________________________________________________
Please list any ministry involvement: ___________________________________________________________________
Church attended in childhood: ________________________________________________________________________
Have you been baptized?

Yes No

If yes, when and where? _________________________________________

If applicable, what is the religious background of your spouse: _______________________________________________


Spouses church attendance: _______ (times per month)
Do you and your spouse openly discuss and encourage one another in your faith?
Do you pray to God?

Yes No

Yes No

If yes, how often? __________________________________________________

What do you pray about? _____________________________________________________________________________


Have you received Jesus Christ personally as your Savior? Yes

No

Uncertain Dont know what you mean

How would you define the Gospel and what it means to be a Christian? ________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you read the Bible?

Yes No

Do you have personal devotions?

If yes, how often? __________________________________________________

Yes No If yes, how often? __________________________________________

Describe your personal devotions: ______________________________________________________________________


Do you have family devotions?

Yes No If yes, how often? ____________________________________________

Describe your family devotions: ________________________________________________________________________


Favorite Christian authors: ____________________________________________________________________________
Please note any recent changes in your spiritual life: _______________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Grace Biblical Counseling Ministry

HEALTH INFORMATION
Have you had counseling before?
Age

Duration

Yes No

Counselor / Center

Have you seen a psychiatrist before?

Issues(s) / Topic(s) / Diagnosis

Yes No Currently

Your Evaluation of Counseling*

* Use back of this page if necessary or if you need more space


Approximately how many hours of sleep do you get each night? ______________________________________________
When do you normally: go to bed? ________ fall asleep? _________ wake up? _________ get out of bed? _________
What do you normally do between going to bed and falling asleep? ___________________________________________
Describe any recent changes in sleep habits: ______________________________________________________________
State of current health: Very good Good Average Declining Other: ______________________________
Date of last medical examination: ____________________ Results: ___________________________________________
Current illness, injury, or disability: _____________________________________________________________________
Are you presently taking any medication? Yes No
Medication

Dosage

Prescribing Doctor(s): ________________________________

Frequency

Prescribed for

Date began taking

Use back of this page if necessary or if you need more space.


Have you used drugs for other than medical purposes? Yes No If yes, when?_____________________________
What? ___________________________________________ Amounts/Dosages: ______________________________
Do you drink alcoholic beverages? Yes No If yes, how often? __________________________________________
How much?____________________ What type?_______________________________________________________
Describe your eating habits or changes in appetite: ________________________________________________________
Describe your exercise routine: ________________________________________________________________________
Weight changes: 6 months +/- _____ lbs.

1 Year +/- _____ lbs.

5 Years +/- ____ lbs.

Number of non-working hours per week spent: watching television _______ on computer _______ hobbies _______
Please check any of the following physiological symptoms that apply to you:
Headaches .. Past Present Difficulty Breathing..

Past Present

Rapid Heart Rate .. Past Present

Visual Trouble Past Present Tension .

Past Present

Dizziness .. Past Present

Weakness Past Present Fatigue ..

Past Present

Pain .. Past Present

Sleep Trouble . Past Present Change in Appetite ..

Past Present

Other (on back) .. Past Present

Indicate how distressed you are by circling a number on the scale below (1 = very little distress; 10 extreme distress):
1

Grace Biblical Counseling Ministry

10

Check any of the following struggles you and/or your family are experiencing at this time:
Please rate: leave blank if none; 1 if mild; 2 if moderate; or 3 if severe.
Who do you mean by family (mark one)? Home of Origin Spouse & Children Extended Family
Abuse, Physical __ You __ Family
Abuse, Sexual... __ You __ Family
Abuse, Verbal . __ You __ Family
Abuse in Past .. __ You __ Family
Addiction ..... __ You __ Family
Adultery .. __ You __ Family
Anger ..
__ You __ Family
Anxiety .....
__ You __ Family
Apathy .... __ You __ Family
Bad Memories. __ You __ Family
Bitterness __ You __ Family
Caring for Parents
.... __ You __ Family
Chronic Pain...... __ You __ Family
Codependency...... __ You __ Family
Communication, Affection
. __ You __ Family
Communication, Day-to-Day
. __ You __ Family
Communication, Emotions
. __ You __ Family
Communication, Planning
.. __ You __ Family
Communication, Problem Solving
. __ You __ Family
Compulsions...... __ You __ Family
Depression...... __ You __ Family
Debt .......... __ You __ Family
Discontentment __ You __ Family
Divorce Recovery __ You __ Family

Doubt Salvation __ You __ Family


Eating Disorder .... __ You __ Family
Empty Nest __ You __ Family
Envy........... __ You __ Family
Fear .......... __ You __ Family
Financial Management
.... __ You __ Family
Greed........ __ You __ Family
Grief......... __ You __ Family
Guilt.......... __ You __ Family
Homosexuality..... __ You __ Family
Humility. __ You __ Family
Identity........ __ You __ Family
Impatience.... __ You __ Family
Infertility....... __ You __ Family
Insecurity...... __ You __ Family
In-Law Conflict.... __ You __ Family
Jealousy...... __ You __ Family
Judgmental....... __ You __ Family
Leadership.... __ You __ Family
Lifestyle Change.. __ You __ Family
Loneliness..... __ You __ Family
Lying ....... __ You __ Family
Manipulation ... __ You __ Family
Marital Intimacy.. __ You __ Family
Moodiness...... __ You __ Family
On-Line Sins...... __ You __ Family
Panic Attacks..... __ You __ Family
Parenting .......... __ You __ Family

Parenting Adult Child


. __ You __ Family
Peer Pressure.... __ You __ Family
People Pleasing. __ You __ Family
Perfectionism.... __ You __ Family
Pornography...... __ You __ Family
Pre-Marital Sex.... __ You __ Family
Pride.................. __ You __ Family
Priorities............ __ You __ Family
Procrastination.. __ You __ Family
Purpose, Lack of... __ You __ Family
Rebellion __ You __ Family
Rejection.. __ You __ Family
Relationships.... __ You __ Family
Respecting Authorities
. __ You __ Family
Respecting Parents __ You __ Family
Respecting Spouse __ You __ Family
Same Sex Attraction
.. __ You __ Family
Self-Control.. __ You __ Family
Self-Injury........ __ You __ Family
Selfish ............... __ You __ Family
Shame.. __ You __ Family
Social Anxiety. __ You __ Family
Spiritual Growth.. __ You __ Family
Submission..... __ You __ Family
Suicidal Thinking.. __ You __ Family
Time Management __ You __ Family
Work Unfulfilling.. __ You __ Family

If you were reared by someone other than your own parents, briefly explain: ___________________________________
__________________________________________________________________________________________________
Number of: Older brothers: ______

Older sisters: ______

Younger brothers: ______

Younger sisters: ______

Step/half: ______

Step/half: ______

Step/half: ______

Step/half: ______

The town I grew up in was: urban

suburban

My familys financial situation was: poor

small town

lower middle

rural

middle class

changed frequently.
upper middle class

Did you have any significant traumatic events as a child? Yes (please describe on back) No
Which of the following words best describe your home of origin (check all that apply):
Traditional

Authoritarian

Unpredictable

Divorced

Lonely

Substance Abuse

Physical Abuse

Verbal Abuse

Perfectionist

Critical

Sexual Abuse

Affectionate

Affirming

Permissive

Safe

Grace Biblical Counseling Ministry

wealthy.

Please complete the following in one or two sentences:


In order to understand me ____________________________________________________________________________
My ambition in life is to ______________________________________________________________________________
What really hurts me is _______________________________________________________________________________
I get nervous when __________________________________________________________________________________
I wish I could lose my fear of __________________________________________________________________________
What I wish I could change about myself is _______________________________________________________________
My best childhood memory is _________________________________________________________________________
My worst childhood memory is ________________________________________________________________________
My father is/was ____________________________________________________________________________________
My mother is/was ___________________________________________________________________________________
My biggest regret is __________________________________________________________________________________
My greatest achievement is ___________________________________________________________________________
My role in my current family is _________________________________________________________________________
For refuge/rest I turn to ______________________________________________________________________________
When life gets too hard I _____________________________________________________________________________
To be happy I need __________________________________________________________________________________
I would do anything for _______________________________________________________________________________
I often wonder why __________________________________________________________________________________
It embarrasses me to ________________________________________________________________________________
I cannot decide _____________________________________________________________________________________
1. Please describe the current problem, as you understand it. ________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2. What have you done about it (most effective and least effective)? __________________________________________
__________________________________________________________________________________________________
3. Other than counseling, what help are you seeking? ______________________________________________________
__________________________________________________________________________________________________
4. Who referred you to GBCM for help? _________________________________________________________________
5. What are your expectations in coming here? ___________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
6. What, if any, are your concerns about coming to counseling? ______________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
7. What do you believe you will have to change to see the progress you desire? _________________________________
__________________________________________________________________________________________________
8. Is there any other information we should know? ________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Thank you for taking the time to complete these forms. The information you have provided will enable us to better serve you.

Grace Biblical Counseling Ministry

Grace Biblical Counseling Ministry Policy Review


Instructions for Policy Review: After carefully reading each policy please place your initials (beside each dark arrow) in
the space provided to indicate your understanding and agreement with each policy. If you have questions, please direct
them to your counselor before your initial meeting. If for any reason you are unable to sign these forms, we will be
unable to serve you.
Not Professional Advice: If you have legal, financial, medical, or other technical questions, you should seek advice from a
professional with expertise in those fields.
MINSTRY CONTRIBUTION POLICY
GBCM will provide counseling, free of charge, as a ministry to help others. Because Grace Baptist Church provides the
facilities and the counselors volunteer their time, we can offer the counseling free of charge. Out of respect for our
staff, counselees are required to pay a $25 deposit before counseling begins which is forfeited for last minute
cancellations. If a counselee leaves counseling or graduates from counseling without a late cancellation, the deposit is
returned. Counselees are also expected to pay for materials used to assist them. Counselees are also encouraged that if
they are pleased with the counseling they received and would like to have a part in meeting the financial needs of the
counseling ministry, they can give a financial gift to GBCM. All contributions are tax deductible.
*** Initial here if you understand and agree with this Ministry Contribution Policy: __________
APPOINTMENT CANCELLATION POLICY
We do not charge for counseling, but we do charge if you do not show up for an appointment. We require a 24 hour
notice if you wish to cancel or are unable to keep an appointment. E-mail is not an acceptable form of contact. If you
fail to give us a 24 hour notice you will lose the $25 deposit.
*** Initial here if you understand and agree with this Appointment Cancellation Policy: __________
PHILOSOPHY OF CARE
We are committed to providing a balanced and biblical approach to counseling. Our counseling is based solely on the
principles of Scripture and does not employ the teachings or methods of modern psychology or psychiatry. By biblical
counseling we mean that your counselor is a Christian with special training and experience in applying the truths of the
Bible to life. We believe that the Bible speaks to all of life and to all of its problems, but sometimes it takes careful
thought and prayerful wisdom to know how to make those connections. We dont believe that the Bible is simply a
how-to book or a recipe book for happiness.
We believe that the Bible ultimately points us to a person and a relationship: Jesus Christ as our Savior and Redeemer.
We believe that real change comes when people learn to see themselves and their problems in the context of a living,
vital relationship with Christ. This does not mean that you must be a Christian to profit from our counseling, although
we believe that deep and lasting change is brought about only by God Himself. However, the Bible is never brought to
bear in an artificial or heavy-handed way.
*** Initial here if you understand and agree with this Philosophy of Care: __________
CONFIDENTIALITY CLAUSE
The Director and staff of the Grace Biblical Counseling Ministry (GBCM), understand that confidentiality is an important
and vital aspect of the counseling relationship. To that end, GBCM and its representatives agree to carefully guard the
information entrusted to them by counselees to the fullest extent possible.
Staff members and trainees participating in the GBCM program are expected to protect the information they receive in
order to ensure the integrity of the counseling process and the privacy of the counselee. Should a counselor or trainee
fail to protect said information, it may become necessary for them to be dismissed from service in the GBCM program.

Grace Biblical Counseling Ministry

Under certain circumstances, however, it may be necessary to reveal information obtained in the counseling process in
order to uphold the principles of Scripture, the standards of Grace Baptist Church, and/or the laws of the state of
Missouri. GBCM 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
counselees 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.
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 GBCM counselor and/or the Director, if such is available, who will work with them to assess the
situation and assist in making the appropriate notifications, if necessary.
4. If the counselor is privy to evidence that abuse or some other crime has been or is about to be committed, it
may be necessary to reveal such information to the legal authorities.
5. GBCM recognizes that in the course of the loving discipline of their children, Christian parents may employ
corporal punishment, in accordance with the teachings of Scripture and, in conformity with those Scriptures,
GBCM supports a parents right to do so. However, if in the course of counseling, the counselor suspects that a
minor child has been physically or sexually abused, the counselor will immediately consult with another GBCM
counselor and/or the Director who will assist in the assessment of the situation. If it is then suspected that abuse
has occurred, the legal authorities will be contacted. If no other counselor is available and a child is in imminent
danger of being abused, the counselor will contact the appropriate legal authorities without employing the
above consultation process.
6. Observers, including but not limited to, counseling trainees, may sit in on counseling sessions, either to assist in
the counseling process or for training purposes.
7. All observers and counselors agree to be bound by this confidentiality agreement and should they be found to
be in violation of this agreement understand they face expulsion from the GBCM counseling program by the
GBCM Director.
*** Initial here if you understand and agree with this Confidentiality Clause: __________
WAIVER OF LIABILITY
In seeking counseling from GBCM, you must acknowledge your understanding of the following conditions and further
release GBCM, its staff, counselors, and all organizational leadership from any legal liability, claim, or litigation arising
from your participation in this voluntary program:
1. Counseling will be provided by ordained ministers (or men and women who are recognized as having
exceptional character and leadership qualities by their church) who have had training in biblical counseling. The
counseling staff members are not licensed counselors through the state of Missouri;
2. All counseling is provided in accordance with the biblical principles adhered to by GBCM and are not necessarily
provided in adherence to any local or national psychological or psychiatric association;
3. No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the
above mentioned counselors, is accepted as customary psychological and/or psychiatric therapy within the
definitional terms utilized by those professions;

Grace Biblical Counseling Ministry

4. It is understood by the participant counselee(s) that all complaints and grievances will be heard by the pastors
and/or deacons of Grace Baptist Church. If the goal of reconciliation cannot be achieved between the
aforementioned parties, then the participant counselee(s) may elect to involve Peacemaker Ministries, Inc., at
their expense, for the purpose of mediation or arbitration.
*** Initial here if you understand and agree with this Waiver of Liability: __________
CONSENT TO COUNSEL
Having read and understood GBCMs
Ministry Contribution Policy
Appointment Cancellation Policy
Confidentially Clause
Waiver of Liability

Philosophy of Care

I, _________________________________________________________________ (print name)


grant permission for Grace Biblical Counseling Ministries to render counseling services to me and the names listed below
(please include the names of those who may be involved in the counseling process):
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
I also understand that GBCM may terminate services for noncompliance with the plan of care and/or agreed upon
administrative issues, failure to keep or properly cancel appointments, violent behavior, threats of violence, involvement
in criminal behavior, or for other similar issues.
*

Please sign to indicate the following:


1. You have read the policies in this document;
2. You agree with and understand each of these policies; and,
3. You are enrolling yourself into counseling of your own will.
______________________________________________
Counselee Signature

______________________________
Date

______________________________________________
Counselee Signature (for spouse or second counselee)

______________________________
Date

______________________________________________
GBCM Counselor Signature

_____________________________
Date

Grace Biblical Counseling Ministry