COTH Biblical Counseling Intake Form

Welcome to the Biblical Counseling Ministry of Church on the Hill. We are grateful that you are inviting us into your life at this time. We admire the courage, faith, and humility this first step represents. We're praying that God will bless your decision and use our time together to encourage the growth and change needed to build a life transformed by encounters with Jesus Christ.

We are confident that through the Scriptures and the power of the Spirit, God has given us everything we need for life and godliness (2 Peter 1:3-4), and it is our joy to help real people with real problems by using these unparalleled tools.

As a church, we are committed to helping one another glorify God with their thoughts, words, and actions through the community of faith. This is made possible by the redemptive power of Jesus Christ, the conviction and guidance of the Holy Spirit, and the instruction of God’s Word. Your counseling will be biblical, pastoral counseling in which the Scriptures are held as the final authority in all matters.

The next step in the counseling process is to complete the following intake form. We have designed them to allow the counseling process to start smoothly and to allow us to connect you with the resources that best fit your needs. The intake form is 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. Fill in as many of the applicable areas as you can; allowing at least 30 minutes to complete them.

Please read through everything carefully and contact us with any questions. We are grateful to be able to serve you and look forward to walking with you through God’s purpose for your life.

The COTH Biblical Counseling Team
503-378-0463

Your name *

Email address *

Personal Data

Birthdate *

Are you over 16? *

For consent to counseling purposes, please answer yes or no to this question.

Yes

Requesting what type of counseling: *

Occupation *

Employer *

Gender *

Phone number *

Address

Referred By *

How did you hear about us? *

Emergency Contact Information

Name *

Relationship *

Phone number

Email *

Marriage & Family Information

For marriage counseling, we ask both spouses to fill out the form separately.

Marital status *

Children: List each child's name, age, and gender *

Spiritual/Religious Information

Are you currently attending a Church? If yes please provide: Church Name, and how many times you attend each month *

If you are not connected to a church currently you can say "none"

Are you currently connected to a life group/small group, bible study or other ministry communities? *

Have you received Jesus as your personal Savior? *

How would you define the gospel and what it means to be a Christian?

Have you been baptized? If so, when?

Health Information

Are you currently taking prescription medication? *

How would you describe your overall general physical health?

How often do you exercise?

How is your sleep?

Do you have any mental health-related concerns (anxiety, depression, OCD, bipolar, etc.)?

Do you struggle with suicidal thoughts?

Presenting Issues

Describe the current struggle for which you are seeking counseling. *

What have you done about it (most effective and least effective)? *

Please describe any family history that might be pertinent to your reason for seeking counseling. *

Any further information that we should know? (relationship in family of origin, significant losses or events, etc.)

Special requests or accommodations:

List days and times you are available for an appointment. *

**Limited availability may result in longer wait times.

Counseling Hours

We look forward to helping you. Due to the nature of our ministry and that it is funded with the support of generous donations from our community, we do have limited hours. If this is an emergency, please call 911 or Marion County Crisis Center at (503) 585-4949.

We are unable to provide childcare for appointments, and children are not allowed to wait in our waiting area. Thank you for your understanding.

Anything else you’d like to let us know about your availability?

Philosophy of Care

We are committed to providing a balanced and biblical approach to counseling. By biblical counseling, we mean that your counselor is a Christian with special training and experience in applying the truth of the Bible to life. We believe that the Bible speaks to all of life and to all its problems, but it takes careful thought and prayerful wisdom to know how to make those connections. We don’t believe that the Bible is simply a how-to book for happiness.

We are confident that through the Scriptures and the power of His Spirit, God has given us all the instruction necessary for life and godliness (2 Peter 1:3-4). It is our joy to help real people with real problems using the Bible. Your counseling will be biblical, pastoral counseling in which the Scriptures are held as the final authority in all matters.

Most importantly, we believe that the Bible ultimately points us to a Person – the Lord Jesus Christ. We believe that real change comes when people learn to see themselves and their problems in the context of a loving, 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. Because of this, we do not use the Bible in either a superficial or heavy-handed way.

When necessary, we will work with your physician or other professionals to ensure you receive the appropriate medical care in conjunction with the counseling services you receive.

The Biblical Counseling Ministry Team

COTH Biblical Counseling Ministry utilizes the help of both trained lay volunteers and pastors. Counselors will honestly tell you if they require additional assistance from another member of the Biblical Counseling Ministry. Please understand that biblical counseling consists of Christians providing scriptural advice and practical application. Yet the counselee is held fully responsible for how he/she implements that advice (James 1:23-25). In addition, our counselors are neither psychologists nor professional counselors. The counseling team consists of pastors, lay counselors, and trainees under the direction of the church elders who provide guidance and oversight. The staff of COTH Biblical Counseling Ministry will supervise the trainees and lay volunteers. A biblical counselor trainee may be present in any counseling session for training and observation.

Expectations as a Counselee

As a counselee, you have the right to discuss outcomes and challenges regarding the counseling and receive an estimate of the predicted length, goals, and outcome of the counseling, as well as alternative options to that counseling. You have the right to ask about and/or refuse any techniques used. You are encouraged to report to an elder/pastor or counseling director if you have any grievances regarding the counseling. You may terminate counseling at any time, but we encourage you to consult with your counselor as to the best way to do so.

Not Professional Advice:
If you have significant legal, financial, medical, or other technical questions, we may help you seek advice from an independent professional in that field.

Referral Process:
We believe in biblical counseling and the future support of the Body of Christ once counseling is completed. However, in the case that progress is not being made, a conflict of interest, or for medical concerns, we do make referrals. With your permission, we will work with your family physician and insurance to help seek medical or professional care if needed.

Assignments:
There will be times where your counselor believes that actions steps will benefit you in your counseling journey. While we hesitate to call these steps “homework,” it is expected that, through the goal setting you design with your counselor, you will commit to seeing these assignments through. If your counselor believes that these will be helpful to your healing journey, and you agree to complete what is asked of you, then we trust that you will follow through. If at any point your counselor feels that your dedication to that process is not meeting the assignment expectation, then a sit-down evaluation to determine your commitment to the process will take place with our pastoral overseer before continuing counseling.

Cancelation/No Show:
It is the expectation that you, as a counselee seeking services provided by COTH’s counseling ministry, commit to your agreed upon appointments with your counselor. While this is what is expected to be the norm, we do understand that there are times where unavoidable events arise. In those cases, we will of course extend grace. We do ask that you contact your counselor as soon as possible to let them know of the change and make arrangements for a different time to meet. During the course of your set counseling period, if you need to cancel your appointments more than three times, then a re-evaluation of the timing for counseling for you will be discussed between you and our Pastoral overseer.

As a counselee, you are allowed one no-show during your counseling period. If a second no-show happens, we would humbly ask that you postpone your counseling until a time when your life allows for the structure and investment that the counseling process takes.

Please type your name for signature you have read and understood our Philosophy of care and your rights as a counselee *

Confidentiality Clause *

Confidentiality is an important aspect of the counseling process. We carefully guard the information you entrust to us to the fullest extent possible. As a church-based counseling ministry, we do not offer absolute confidentiality. There are times when it may be necessary for us to share specific information with others. Examples include but are not limited to matters of church discipline (cf. Matt 18:15 ff.), divorce, and separation, which may include notifying the pastor/elder of the counselee’s attending church, criminal activities, and potential harm to self or others. Additionally, when a counselor is uncertain how to address a particular situation, the counselor may consult with another member of the Biblical Counseling Ministry team at Church on the Hill for the purpose of providing the highest level of care within the ministries of the church. To best care for you, we will work together as a ministry team while keeping the circle of confidentiality as tight as possible.

Please be aware that as part of our ongoing training and quality assurance practices we may have another counselor in the room to observe during sessions.

There are times when counseling information may be shared outside the church context. Those exceptions would include, but are not limited to, the following:
- Known or suspected abuse of any kind
- The intent to take criminal actions or violence against another person
- Credible suicidal thoughts or intentions

If you are suicidal during the course of your counseling with your counselor, it is crucial that you talk with your counselor about these matters. By signing below, you agree to share any suicidal thoughts or intentions with your counselor at any time they arise and by phone if they occur in between sessions, and that you will seek medical care if you become suicidal in the course of your counseling.

In the case of marriage or family counseling, there is limited confidentiality, meaning the confidentiality belongs to the couple and not the individual.

Confidentiality for counseling at Church on the Hill is defined by pastor-parishioner privilege because we are a local church, and our counselors operate as agents of the church (pastors/ministers), not agents of the state (licensed counselors). This means counseling conversations are inadmissible in a court of law. All counseling forms and notes taken by the counselor are the property of COTH Biblical Counseling Ministry. They are protected as confidential and may not be used in court proceedings or in any other way that is not authorized by the Biblical Counseling Ministry Team. If your counseling needs require professional representation in a court setting by a counselor, COTH Biblical Counseling will likely not be the best fit for your needs.

Type name for signature below

Waver of Liability *

In seeking counseling from COTH Biblical Counseling Ministry, please acknowledge your understanding of the following conditions and further release Church on the Hill, its elders, staff, counselors, employees, and all ministry team leadership from any legal liability, claim, or litigation arising from your participation in this voluntary program:

1. Counseling will be provided by pastors or church-trained lay leaders. The counseling staff is not a licensed counseling service through the state of Oregon.

2. All counseling is provided in accordance with the biblical principles adhered to by Church on the Hill and is not necessarily provided in adherence to any local or national psychological or psychiatric associations;

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;

4. In consideration for receiving any form of counseling from ________________, the person receiving the counseling agrees to release and waive any and all claims of any kind against the ministry, the staff, the pastoral/lay encouragers, or any participating church, which may arise from, result out of, or be related to conduct or advice given.

Type name for signature below

COTH Biblical Counseling Policies *

I understand that Church on the Hill may terminate services for noncompliance with the agenda of care and/or agreed-upon administrative issues, failure to keep or cancel appointments, criminal misconduct, violence, or other similar issues.

Having clarified the principles and policies of our counseling ministry, we joyfully anticipate the opportunity to walk with you as Christ enables you to grow in spiritual maturity and usefulness to His body. If you have any questions about these guidelines, please speak with your counselor or call the church office at (503)378-0463.

Type name for signature

Counseling Advocate *

We believe in receiving help within the community of God. To ensure you have support both inside and outside of the counseling setting we ask that you choose a close friend, family member, or mentor to attend your counseling sessions alongside you for the best well-rounded support during this time. We understand that this is not always possible, and while we strongly encourage this practice, it is not a determining factor in you receiving the counseling you are seeking.

Please let us know if you need help finding someone who can stand with you as an advocate.

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