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biblical counseling.

BIBLICAL COUNSELING QUESTIONNAIRE

Personal Information

Marital Status:
Single
Engaged
Married
Separated
Divorced
Widowed

Marriage & Family

Have either of you been previously married:
Yes
No
Have you ever been separated:
Yes
No
Have either of you ever filed for divorce:
Yes
No

Health

Do you have any chronic conditions:
Yes
No
Have you ever used drugs for anything other than medical purposes:
Yes
No
Have you ever been arrested:
Yes
No
Do you drink alcoholic beverages:
Yes
No
Do you drink coffee:
Yes
No
Do you drink other caffeinated drinks:
Yes
No
Do you smoke:
Yes
No

Spiritual

Member:
Yes
No
Church attendance per month:
0
1-2
3-4
5-6
7-8
8+
Do you believe in God:
Yes
No
Do you pray:
Yes
No
Would you say you're a christian, or still in the process of becoming a christian:
Yes
No
Have you ever been baptized:
Yes
No
How often do you read the Bible:
Never
Occasionally
Often
Daily

Women Only

Is your husband willing to come for counseling:
Yes
No
Is your husband in favor of you coming:
Yes
No

Problem Checklist

Click All That Apply:

Briefly Answer The Following:

Moriah Church Biblical Counseling

Policies and Procedures/

Consent to Counseling

BIBLICAL COUNSELING CONSENT FORM

Our Goal:

The mission of Moriah Church Biblical Counseling is to equip you to meet the challenges of life by transforming power of Jesus Christ for the glory of God. We offer counseling free of charge as a ministry of Moriah Church. Counselees may donate to the ministry, but this is not expected or required as a condition of counseling. You have no express or implied obligation to pay fees for counseling you receive at Moriah Church.

 

Biblical Basis:

Moriah Church counseling is strictly religious and in nature, conducted under the authority and leadership of the church.

We believe that God, through His revelation in the Old and New Testaments of the Bible has provided His people with thorough guidance and instruction for faith and life (II Timothy 3:16-17; I Peter 1:3-4). Our counseling is based solely on scripture principles. We reject the teaching and methods of modern psychology or psychiatry, whether expressly secular or an attempted integration with biblical principles. Moriah Church counselors are not trained or licensed as psychotherapists or mental health professionals. They do not follow the method of such persons, and our policy is to not make referrals to them.


Other Professional Advice:

If you have significant medical, legal, financial, or other technical questions, you should seek the advice from competent independent professionals. Our counselors will cooperate with such advisors and help you to consider their counsel in the light of scriptural principles.

 

More specifically, we urge our counselees to properly care for their physical bodies and to seek proper medical treatment for all physiological problems. Our counselors will assist you in responding to such problems in a godly manner, but our counsel is not intended to replace the services of a qualified physician where organic problems are present or where medication has been prescribed.

 

Confidentiality:

Confidentiality is an important aspect of the counseling process. We will guard the information you entrust to us with the fullest extent possible. There are times, however, when it may be necessary for us to share certain information with others. Examples include, but not limited to, the following:

 

1.   Where a person refuses to renounce a particular sin, it may become necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 12:22; Matthew 18:15-20). In such cases, we will reveal only such information as is necessary for such purposes, and only to those biblically required to be involved. Where a counselee is a member of another church, it will most likely be necessary to contact the pastor and/or elder(s) of such church.

                                                                                         

2.   Where a counselor is uncertain as to how to address a particular counseling issue, he/she may seek advice from a pastor or another counselor.

 

3.   Where a counselee threatens harm to another person, it may be necessary to intervene to prevent such harm.


4.   The law may require a counselor to reveal spousal or child abuse, or some other crime, to appropriate authorities.

 

5.   Observers may sit in on counseling sessions, either to assist in the process or for training purposes.


Conflict Resolution - Arbitration:

On rare occasions, a conflict may develop between a counselor and counselee. I Corinthians 6:1-8 forbids Christians from bringing lawsuits against another in secular courts of law. To ensure that such conflicts are resolved in a biblically faithful manner, we require all of our counselees agree that any dispute with a counselor or with this church will be settled in mediation and, if necessary, legally binding arbitration conducted in accordance with Rules of Procedure of the Institute for Christian Conciliation. (A copy available on request). The arbiters will be the elders of Moriah Church. When one or more of the church elders is party to the dispute, they choose an arbiter, and the two arbiters then select a third. It is expressly understood that, by consenting in advance to such arbitration, the counselee waves his/her right to a trial in civil courts. By signing this consent, you agree that you will not attempt to subpoena or require any counselor to appear in legal proceedings related to the matters discussed during counseling; nor will you attempt to subpoena any notes or records related to this counseling.


If you do not have your paperwork in on time, we will have to give your slot to the next person on our wait list.


Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about the guidelines, please speak with your counselor. Your signature indicates your informed consent to these guidelines.

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CONTACT

Moriah Church

4890 N 370th St
Casey, IL 62420

Moriah Outreach Center

107B W Main St

Casey, IL 62420

217-609-0800

Office Hours:

M, W, F

9 AM-12 PM

Mailing Address:

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