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.
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: ______________________________________________________
Occupation/Employer: ____________________________________________
Birth Date: ______ / ______ / _________
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
# Kids
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).
Yes No
Yes No
Yes No
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
Yes No
Yes No
No
How would you define the Gospel and what it means to be a Christian? ________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you read the Bible?
Yes No
HEALTH INFORMATION
Have you had counseling before?
Age
Duration
Yes No
Counselor / Center
Yes No Currently
Dosage
Frequency
Prescribed for
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
Past Present
Past Present
Past Present
Indicate how distressed you are by circling a number on the scale below (1 = very little distress; 10 extreme distress):
1
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
If you were reared by someone other than your own parents, briefly explain: ___________________________________
__________________________________________________________________________________________________
Number of: Older brothers: ______
Step/half: ______
Step/half: ______
Step/half: ______
Step/half: ______
suburban
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
wealthy.
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;
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
______________________________
Date
______________________________________________
Counselee Signature (for spouse or second counselee)
______________________________
Date
______________________________________________
GBCM Counselor Signature
_____________________________
Date