PERSONAL DATA INFORMATION Step 1 of 7 14% Consent to Counseling Grace Church provides biblical counseling as a free ministry to help you to Identify godly ways to resolve problems Cope with difficult circumstances and Honor God in the way you respond to all of life's challenges and opportunities. Our counseling is biblical in nature, not psychological, being based on the belief that we were created by a loving God who has, through His Word and His Spirit, given us the ability to succeed in life and to "become blameless and harmless, children of God without fault in the midst of a crooked and perverse generation, among whom you shine as lights in the world, holding fast the word of life" (Philippians 2:15-16). The state of Missouri licenses psychological but not biblical counselors, therefore our counseling pastors are not licensed as counselors. If you would prefer to work with a licensed psychological counselor, we can refer you to one. The counseling process is typically a confidential discussion in which private information must be shared in order to identify root problems and scriptural responses. However by proceeding to fill out this form the counselee acknowledges that there are exceptions to this. The staff works as a team. The counselor may consult with other staff to provide the best possible care. These consultations are for professional, prayerful and training purposes. The church works as a team. Therefore if necessary the counselor may confer with other church leaders on rare occasions when deemed appropriate and necessary. The counselor may also include unidentifiable, anonymous references in teaching settings. (i.e. Authors, pastors and teachers often cite examples of problems they've helped people overcome.) If there is evidence of clear and imminent danger of harm to self or others, a counselor is legally required to report this information to legal authorities responsible for ensuring safety. The law requires that counselors who learn of, or strongly suspect, physical or sexual abuse or neglect of a child must report this information to legal authorities. A court order, issued by a judge, could require the church to release information contained in records and/or require a counselor to testify in a court hearing. Of course, to give wise counsel we first need to know all the pertinent facts. Therefore we ask a lot of questions, so we can see the big picture. So please fill out all questions in the Personal Data Inventory thoroughly, even if they seem irrelevant at the moment. (Sometimes we can only determine that info is impertinent when we see it; at other times we find important clues hiding in obscure details.) There is no fee for counseling services. If you are referred to health or counseling professionals off campus, you are responsible for their charges. By typing in your name below you acknowledge that you have read this, understood it and agreed to it. Pastor Counseling YouDon't KnowMarty HaasRachel KleinBob PickettPhil EppardName* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age Education Grade School High School Some College Associates Degree Bachelor's Degree Masters Degree Doctoral Degree Last year completedOccupation: Employer & Position* How long employed with this employer?* Marital Status* Unattached, Never Married Not Married, but Living With a Partner Not Married, but Dating Seriously or Engaged Married Divorced Remarried After Divorce Widowed Remarried After Being Widowed Parental Status* No Kids Have Kids/Stepkids at Home Have Adult Kids/Stepkids Briefly describe what problem has led you to seek counseling?* MarriageSpouse Name* Spouse's Phone*Spouse's Email* Spouse Age* Spouse's Education Grade School High School Some College Associates Degree Bachelor's Degree Masters Degree Doctoral Degree Last year completedSpouse Occupation: Employer & Position Spouse Occupation: How long with this employer? How long did you date?* Briefly describe how you met and describe your dating period.* Date of Marriage* How many times have you been married?*Please enter a number from 1 to 9.How many times has your spouse been married?*Please enter a number from 1 to 9.Briefly describe your marriage.* Parenting InfoHow many children/stepchildren do you have?*Please enter a number from 1 to 18.For each child, please list his/her: Name, Age, Gender, Education Level, whether they live with you and whether they are your biological child or stepchild. Begin each child on a new line.*Example: Dennis, 20, Male, College Student, Lives in Mizzou College Dorm, Biological Childhood BackgroundDescribe the home in which you grew up. Check all that apply.* I was raised by both of my biological parents My parents got divorced while I was growing up My parents got divorced after I was on my own My parents are still married to each other My mother has passed away My father has passed away I didn't know my father well, if at all My parents argued a lot My parents almost never argued My parents were very affectionate in front of us One or both of my parents were abusive to each other My parents were strict but fair One or both of my parents were abusive to one or more of the kids My parents were good role models I have a good relationship with my mother I have a good relationship with my father There was never a doubt that my father loved my mother There was no doubt my mother loved my father There was never a doubt that my father respected my mother There was no doubt my mother respected my father I felt loved growing up How may brothers and sisters do you have?*Birth Order: What number are you?*Siblings | In order of age, please list each of your brothers and sisters, giving us this information: Name, Age, Marital Status, Relationship With You Today. Begin a new line for each sibling.*Example: Dan, 35, Divorced and remarried, We get along fine but seldom interact Spiritual BackgroundDid you attend a church growing up? If so, what kind of church?* What church do you attend regularly?* None Grace Church-Saint Louis Grace Church-East Campus Do you believe in God?* Yes No I have doubts If you were to die today, and an angel asked why you should be allowed to enter heaven, what would you say?*How often do you read the Bible?*NeverAlmost neverRarelyOccasionallyAt least 2-3x monthAt least once a weekMost daysWhich best describes when/How often you pray?*NeverRarelyBefore mealsMainly when I'm worried about somethingAt least once a weekAt least once on most daysMultiple times on most daysHow long have you been attending the above church?* How many times per month do you typically attend?*12345678+If there have been any recent changes in your spiritual life, please describe them.* HealthBriefly describe your health.*What chronic conditions, important illnesses, injuries or handicaps do you have?* Name current medications and dosages you take, including both prescription and over-the-counter medicines.* What drugs (including marijuana) do you take for purposes other than medical?* Alcohol: How often and how much alcohol do you drink? When was the last time you got at least a little drunk?*Do you smoke tobacco?*NoNo, but I chewYes, cigarettesYes, but only a very occasional cigarYes, I regularly smoke cigars or a pipeHow much caffeine do you regularly consume?* If you have ever seen a psychiatrist or counselor, please explain the circumstances and outcome.* Example: Saw a licensed counselor for a few years for depression about 8 years ago. I finally quit going because it didn't seem to be helping.What mental health label, if any, has a doctor or counselor ever given you?* Examples: schizophrenic, bipolar, narcissistic, autistic, ADD, ADHD, alcoholic, OCD Personality TraitsCheck any of the following that describe you now.* Active Always Right Ambitious Calm Easy-Going Excitable Extrovert Good-Natured Hard-Boiled Hardworking Imaginative Impatient Kindly Leader Likeable Lonely Moody Nervous Often Blue Opionated Persistent Quiet Self-Confident Self-Conscious Sensitive Serious Shy Spiritual Submissive Check any of the following struggles that describe you now.* Anger Anxiety Apathy Appetite Bitterness Bizarre Thinking/Behavior Boredom Change In Lifestyle Children Choosing A Mate Confusion Deception Decision Making Depression Divorce/Remarriage Doubt Drunkenness Envy/Jealousy Fear Gender Identity Gluttony Grief Guilt Handicap Health Hidden Past Homosexuality Impatience Impotence In-Laws Inferiority Insomnia Irritableness Lack of Motivation Laziness Loneliness Marital Memory Money Moodiness Pain Parenting Pride Procrastination Rebellion Relationships Self-Pity Sex Sleep Issues Spousal Abuse Suffering Suicidal Thoughts Terminal Illness Unfair Treatment Vice By typing your name below and clicking submit, you are confirming your earlier commitment to the terms of counseling outlined on the first page of this form.Name of Individual Consenting to Counseling*
