PDI Form for Spring Lake Church

Completed: 0%

Note: If a question on the form does not apply, please leave it blank.

Name

Address

Address Line 2

City

State/Province

Zip/Postal Code

Primary Phone

Secondary Phone

Email * This will allow you to receive a copy of the completed form.

Referred By

Birth Date (MM/DD/YYYY)

Gender: Male Female

Completed Education

Marital Status

Employer

Position

Years at Employer

Is English your first language?
Yes No If not, what is?

Completed: 12%

What is the main problem, as you see it? What brings you here? - required

What have you done about the problem? - required

What are your expectations in coming for counseling? - required

Is there any other information that we should know?

Does anyone from your church plan to accompany you to counseling? Yes No

If Yes, please indicate his/her name(s), and the nature of your relationship with them.

Completed: 24%

Spouse

Birth Date (MM/DD/YYYY)

Occupation

Years at Employer

Primary Phone

Secondary Phone

Email

Date of Marriage (MM/DD/YYYY)

How long did you date?

Circumstances of meeting and dating (brief)

Is your spouse willing to come for counseling? Yes No If not, please explain

Is your spouse in favor of your coming? Yes No If not, please explain

Have either of you been previously married? Yes No If so, to whom?

Have you ever been separated? Yes No

Have you ever filed for divorce? Yes No

If there have been multiple marriages, briefly explain time frames, children involved, and reasons.

Information About Children:

Additional Children (separate information with commas, one row per child.)

Describe your relationship to your parents

Number of Siblings

Birth order of all siblings

Did you live with anyone other than your parents growing up?

Are your parents living? Do they live locally?

Completed: 36%

Describe your health

Do you have any chronic conditions (pain, headaches, insomnia, etc.)? Yes No If so, what:

List important illnesses and injuries or handicaps

Approximate Date of last exam:

What was the report?

Physician's name and address

Current medication(s) and dosage

Have you ceased taking any drugs recently? Which ones, why, and when?

Have you ever used drugs for anything other than medical purposes? Yes No If so, explain

Have you ever been arrested? Yes No If so, why, when, and was there a resulting sentence?

Do you drink alcoholic beverages? Yes No If so, how frequently and how much

Do you drink coffee? Yes No How much?

Other caffeine products consumed

How much?

Do you smoke? Yes No What: Frequency:

If you have ever had interpersonal problems on the job, please describe them

Have you ever had a severe emotional upset? Yes No If yes, please explain

Have you ever seen a psychiatrist or counselor? Yes No If yes, how was it helpful? Please explain

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records? Yes No

Completed: 48%

Denominational Preference

Church attending I am a member

Location

Pastor's Name

Pastor's Phone Number

Do we have permission to contact your pastor? Yes No If not, please explain why: * Permission to contact your pastor includes sharing information on this PDI.

Church attendance per month:

Do you believe in God?     Yes    No
Do you pray?     Yes    No
Would you say that you are a Christian?     Yes    No    Or interested in becoming a Christian:     Yes    No    Have you ever been baptized?     Yes    No

How often do you read the Bible?

Explain any recent changes in your spiritual life

Completed: 60%

Have you had any menstrual difficulties: Yes No

If you experience tension, tendency to cry, other symptoms prior to your mestrual cycle, please explain

Have you ever had an unplanned pregnancy? Yes No

Have you ever had an abortion? Yes No

If you had an abortion, did you suffer any medical side-effects that would be helpful for your counselor to know?

Completed: 72%

Please select areas you are struggling with.

Completed: 84%

We want your first session to be as profitable as possible. So we ask that you give careful attention to the following document. It will help you understand who we are, what we do and what we ask of you as you enter into our counseling ministry. If you have any questions in regards to any of the items below, please contact the Biblical Counseling office at (920) 983-9090, ext 1038; or email us at counseling@springlakechurch.org

Who Our Counselors Are

Our Biblical Counselors are trained in the meaning and use of the Bible and the biblical principles found in it for counseling. We are committed to the position that Scripture is our only authoritative guide for life and is sufficient for all of life's problems. We do not base our counseling knowledge on our own opinions, experience, or concepts of behavior. We seek to apply biblical truth, in its completeness, when we meet with you and discuss your current issue(s).

Our team of Biblical Counselors deal with a wide range of problems, including broken marriages, parent-child relationships, fear, depression, addictions, abuse, stress, anxiety/worry, and a host of other problems. But know that our counselors are not infallible; they do not pretend to know all there is about biblical teaching and its applications to life, but they are well equipped and competent to help you change. Your counselor will make it a point, when meeting with you, to differentiate between God's commands and their suggestions.

PLEASE NOTE: YOU ARE NOT RECEIVING PROFESSIONAL ADVICE. Although some on our Biblical Counseling team may be licensed in other fields, such as medicine or psychology, they will not be practicing as doctors, psychologists or psychiatrists in their role as your Biblical Counselor. Therefore, if you have significant legal, financial, medical or other technical questions, you will be asked to seek advice from independent professionals not associated with the Spring Lake Biblical Counseling Ministry. Your Biblical Counselor will be happy to cooperate with such advisors and help you consider their counsel in light of relevant biblical principles.

Our Goal

Our goal is provide you with the biblical help that you need to meet the challenges of life in a way that is pleasing and honoring to Christ. We believe that the Bible provides us with everything we need for life and godliness (2 Peter 1:3). Therefore, we do not base our counseling on man-made theories that most psychologists and psychiatrists base their counseling practices on. Understand, the Biblical counsel you will receive will consist of the giving of scriptural counsel and the practical application of Gods Word. Our counselees are held fully responsible for how he/she implements that counsel.

Our team of Biblical Counselors will focus on three basic foundations from God's Word that will redirect you upward towards Christ and less toward your problems. They are:

Hope — Because in Christ we have a great High Priest who has been tempted in all things, yet was without sin. Thus, because of Him, even though every sin common to man may be tempting you, God has promised that He will not let you be tempted beyond your endurance, but will provide for you the way of escape from sin so that you can endure it (1 Cor. 10:13; Heb. 4:14-16).

Change — Because in Christ we can learn how to lay aside the old selfish ways of living and put on the new ways of living in a manner worthy of the Lord, to please Him in all respects, bearing fruit in good work and increasing in the knowledge of God (Eph. 4:20-24; Col. 1:10).

Practice — Because we need to prove ourselves doers of Gods Word, not merely hearers of it, forgetting and deluding ourselves. Only in effectual practice of the Scriptures will we be blessed in what we do, and only then will we please the Lord (James 1:22-25).

We are an Equipping and Training Ministry

Our Biblical Counseling Ministry receives many requests for counseling and our goal is to be able to honor all the requests. To achieve this goal, we are continually expanding the ministry by training new counselors. With this in mind, please be aware that your Biblical Counselor may have a trainee with him/her. Your counselor will advise you when or if a trainee will be present. If having a trainee present would make you feel uncomfortable, please let your counselor know.

CONFIDENTIALITY: Confidentiality is respected but held within appropriate limitations. At times, and with much prayer, your case may be discussed with other Biblical counselors, other professionals, or with one of our Pastors or Elders; this will only happen to the degree necessary to find further biblical solutions to your problem(s). All such consultation will be conducted in accordance with the highest standards of Biblical ethics.

Our team does understand the important aspect of confidentiality and we carefully guard the information you entrust to us. However, absolute confidentiality is not biblical. In certain circumstances the Bible requires that facts be disclosed to selected others (see Matt. 18:15). If a Pastor or Elder of Spring Lake should inquire, we will disclose to them that information which we believe is necessary for them to effectively shepherd and lead you.

PLEASE NOTE: There are five situations when it may be necessary for us to share certain information with others. They are:

When a counselor is uncertain how to address a particular problem and needs to seek advice from the BC Coordinator.
When a counselee attends another church and it is necessary to talk with his/her Pastor.
When there is a clear indication that someone may be harmed unless others intervene.
When a counselee persistently refuses to renounce a particular sin and it becomes necessary to seek assistance of others in the church to encourage repentance and reconciliation (see Matt. 18:15-20; Prov. 15:22, 24:11).
When criminal activity has been committed and the counselee refuses to bring the matter to the attention of local authorities.

Please be assured that your Biblical Counselor strongly prefers not to disclose personal information to others, and will make every effort to help you find ways to resolve a problem as privately as possible.

Counseling Sessions

We will strive to arrange your first session as quickly as possible after receiving your forms.

In our Biblical Counseling Ministry, men meet with men, women meet with women and couples will meet with couples. Due to this, it may take some time to pair you with the appropriate Biblical Counselor. We also do our best to pair you with a Biblical Counselor(s) who has potentially been through whatever trial or circumstance you are currently facing.

Once a Biblical Counselor(s) is chosen and available to meet with you, you will receive an email with instructions for how to schedule your first session. We currently use an online scheduling site (called Acuity Scheduling) to set up your appointment with your counselor(s). Each has their own individual calendar and you will receive a link to their calendar so that you may choose one of their available times that works with your schedule.

You and your Biblical Counselor(s) will receive a confirmation email with your scheduled appointment. If you need to reschedule or cancel your appointment, you will have those options in that email.

PLEASE NOTE: If you cannot use the online scheduling system for any reason, please notify the Biblical Counseling coordinator. If you are not using the online scheduling and you need to reschedule or cancel your appointment, please contact your assigned Biblical Counselor(s) within 48 hours of your appointment time. Failure to notify the counselor(s) or the Biblical Counseling Coordinator of your need to cancel or reschedule may result in being put on our waiting list.

Most of our counseling is done on the Spring Lake Church campus. At times, other locations may be used ~ a neutral location or the counselor's home. We strive to make the location convenient for both of you. Your counselor(s) will confirm the location with you.

If all of our Biblical Counselors are at full capacity and none are available at the time of receiving your PDI, you will be given several options to choose from. The Biblical Counseling Coordinator will contact you to discuss the options. During that call, the Coordinator will briefly discuss your current problem(s) and look to possibly get you in for a one-time meeting with them or with one of the Pastoral staff, as one option. The goal in each option will be to give you hope and a place to start while you wait. This could be a solidly biblical book that would speak to your issue(s) or a passage or book of the Bible to saturate yourself in until you meet with an available Biblical Counselor.

One of our requirements for you as you come into our Biblical Counseling Ministry is that you are in a Small group. Our Small Group ministry is where we 'do life together' as we grow in our Christ-likeness. While we believe that our Biblical counseling ministry can help you with the struggle(s) you are facing, we know that one-hour counseling sessions are just the beginning. We believe that the only way to achieve lasting victory over the problems of life is to become a fully-devoted follower of Christ. The Church helps in this process (Heb. 10:24-25). So you will be required to join one of our many Small Groups and you will be asked to attend one of our weekly Worship services and as soon as possible, we will help you find a place to serve at Spring Lake Church (Bellevue or Downtown site).

Your first counseling session will typically last at least 2 hours. After that, your counseling sessions will, typically, last 1 to 1 1/2 hours every week or every other week. Our goal is to meet with you 10 to 12 times. This will be based on the severity of your problems and on how quickly you respond to the biblical counsel that you get.

EXPECTATIONS AND COMMITMENTS: Your counselor will invest in you, thus, we have certain expectations of you in return. First, it is important that you be honest and willing to trust your counselor. It is difficult for him/her to help if you seek to hide from the truth of your situation. Second, your counselor will typically send you away with homework. We believe that the hard work of change happens more outside of the counseling meetings so your homework will be purposeful and necessary. It will assist you towards genuine and lasting change. And finally, your counselor will be looking for a commitment of time. Problems and bad habits develop over long periods of time and typically can not be broken in just a few days. For this reason, your counselor will be looking for several commitments from you. They are:

You will show up for your scheduled session with your Bible, a notebook, and a teachable spirit.
You will have completed your homework and will be ready to discuss it with your counselor.
You will faithfully attend one of four Worship services offered every weekend at Spring Lake and join one of our various Small Groups.
You will put into practice the Biblical principles that you learn with your counselor so that both of you will see significant change in your life as you respond to life in a Christ-like manner.

If your counselor finds that you are not fulfilling these commitments above, please know that your counselor will first seek to identify the cause of the failure to fulfill them, discuss it with you and help you correct it. If there still is no fulfillment of these four commitments from you, your counselor will view that as a sign that you wish to be released from your counseling sessions and will do so promptly.

Come with high expectations! We are sure that you will find hope and encouragement from your first session to your last. With your cooperation, the Biblical Counseling team is confident that you will find true, good and acceptable answers to the problems that prompted you to come to us.

IN THE EVENT OF A CONFLICT: If there is a conflict between you and your counselor, it will be our goal to ensure that all such conflicts will be resolved in a biblically faithful manner. We require that all of our counselees agree that any dispute that arises with a counselor, or with our church, as a result of counseling, will be settled by mediation within the church according to the principles of Scripture and Peacemakers Ministry, our current Bylaws, and the authority of Spring Lake Church.

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 to grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about these guidelines, please talk with the Biblical Counseling Coordinator.

Consent

I have read the principles and policies of the Biblical Counseling Ministry at Spring Lake Church, and will consent and commit to:

receiving counseling that is based solely on the sufficiency of Scripture and not by man-made theories or philosophies.
acknowledging that my counseling will be conducted by a trained and/or certified Biblical Counselor and not a licensed Professional.
upon my agreement, that a trainee may be present in my session(s).
being encouraged, by my Biblical Counselor, with biblical hope and will be challenged towards change that conforms me to the image of Jesus Christ by the practical application of Gods truth in my life.
being completely open and honest at each meeting with my counselor and that, with Bible and notebook in hand, will come with homework assignments complete and a teachable spirit. If I do not, that could be reason for my being released from counseling.
a certain duration of counseling sessions that are in accordance with my specific issue(s) and with my recognizable growth that comes with responding to circumstances and situations in a Biblical manner.
communicating with my counselor if I can not make my meeting within 48 hours of our set time or else I may be released from our sessions.
acknowledging that a No-Show to my meeting time will automatically release me from counseling.
the idea that biblically there is no absolute confidentiality and acknowledge that my counselor will carefully guard what I have entrusted to him/her and will only use if it will help him/her to continue to walk along with me in my growth towards Christ-likeness.
the truth that my counselor(s) greatest desire is to see me change for the glory of God; and if he/she does not see my commitment to this, that we will discuss my possible release from counseling.
faithfully attending worship services and will actively participate in one of the various Small Groups at Spring Lake. If I do not, that could be reason for my being released from counseling.

Electronic Signature

I, (electronic signature required), have carefully read the conditions for counseling set forth on this page and agree to enter into counseling in accordance with them.

I am filling out this form on behalf of the counselee:

My Name

Relationship

Completed: 100%

Thank you for taking the time to fill out this form! Your complete and honest answers will aid the counseling process and allow the counselor to better understand you and your situation.

We encourage you, if you have not already, to go back and review your answers. Once you click "Finish" an email will be sent to the counseling office at the Biblical Counseling office at Spring Lake Church. If you filled in your email address under the Personal section, you will receive a copy of your PDI.

Your counselor will contact you to set up a meeting time and location that is convenient for both parties. If you have any questions or concerns, please do not hesitate to contact our counseling office.

Click "Finish" to submit your Personal Data Inventory.