Biblical Counseling Intake Form

Your name *

Email address *

Address

Phone number

Employer and Title *

Spouse/ Fiance Name:

Children'(s) Name(s) and Age(s):

Are you a member of Mosaic Church? *

Yes

How long have you been attending Mosaic Church? *

Counseling Session Type: *

What areas are you involved/serving in at Mosaic Church? *

Do you attend a Connect Group? If so which one? *

Have you ever had counseling before? If so when? (Add year & Explanation) *

Mosaic Church | Biblical Counseling Agreement

What has led you to seek Ministry/Counsel at this time? *

What are your expectations or hopes for receiving ministry? *

Do you find discussing your life circumstances easy or difficult? Please explain. *

Have you ever struggled with the following? Past, Present, Never*

Feelings of Inferiority *

Past

Present

Never

Loss of interest in usual activities/lack of motivation *

Past

Present

Never

Suicidal Thoughts *

Past

Present

Never

Suicidal Attempts *

Past

Present

Never

Angry Thoughts *

Past

Present

Never

Angry Outbursts *

Past

Present

Never

Rejection *

Past

Present

Never

Depression *

Past

Present

Never

Eating Disorders *

Past

Present

Never

Lustful Thoughts *

Past

Present

Never

Excessive Anxiety or Worry *

Past

Present

Never

Excessive Fear *

Past

Present

Never

Spiritual Abuse *

Past

Present

Never

Physical Abuse *

Past

Present

Never

Verbal/Emotional Abuse *

Past

Present

Never

Substance Abuse/Addiction (Drugs/Alcohol) *

Past

Present

Never

Unforgiveness *

Past

Present

Never

Sexual Abuse *

Past

Present

Never

Ritual Abuse *

Past

Present

Never

Gambling Addiction *

Past

Present

Never

Nightmares/Difficulty Sleeping *

Past

Present

Never

Under too much pressure/stress *

Past

Present

Never

Inability to express what you really feel/think *

Past

Present

Never

Hearing voices *

Past

Present

Never

Sexual Addiction *

Past

Present

Never

Please rate your anxiety from 0-5: *

(0 is the lowest, 5 is the highest)

Services | Appointments | Rights

Please rate your depression from 0-5: *

(0 is the lowest, 5 is the highest)

SERVICES & COUNSELORS

Type of Counseling: Biblical-based counseling is provided as a ministry to the Mosaic Church family and community to address practical, personal, spiritual, and/or relationship needs. There is no fee for this service. (Biblical-based counseling will adhere to the vision, core values, and guidance provided by the Executive Team of Mosaic Church.)
The Counselor: The counselor is trained and experienced in biblical counseling and/or other areas of Biblical knowledge. We trust the counselor to move with Holy Spirit guidance while serving on the Mosaic Biblical Counseling Team.
Session Duration: The session duration is 50 minutes. The services provided are not intended to be long-term therapy. For this reason, session durations are limited and are not intended to extend beyond 6 sessions.
Session Structure/Objectives: Sessions, resources, and practical exercises are structured to provide sound guidance based on spiritual principles that will lead to spiritual growth and healing. The care seeker is expected to apply the principles and do their best to complete assignments that may be given during sessions. If the counselor feels that the care seeker is not doing her/his part to move forward toward achieving the objectives, the counselor may choose to cancel future sessions.
Next Steps/Referral: All care seekers will be encouraged to take their next step for discipleship or may be referred to a specialized wrap-around service for further care. These Next Steps may be Connect Group involvement, a Mentoring relationship or Professional Counseling.

RIGHT TO PRIVACY/CONFIDENTIALITY

All communication between the member and the counselor becomes part of the Biblical Counseling Department records. Records are the property of Mosaic Church in accordance with legal requirements. While most communication between a member and the biblical counselor is confidential, the following limitations and exceptions do exist: It is required by Tennessee law that any acts of "reasonably suspected" child abuse (physical or sexual), elder abuse, or dependent adult abuse must be reported to the Department of Social Services and/or the Sheriff's Department; If there is concern that an active suicidal risk is present, the counselor will need to involve others to help in providing the necessary care and protection to the care seeker.
The information shared in the counseling session could be discussed with pastoral leadership. Reasonable efforts will be taken to ensure that the identity of the care seeker will not be disclosed. The individual/couple authorizes that Mosaic Church has permission to release records if Mosaic Church is ordered by a court to disclose information. If the member occupies a leadership or ministry position and the counselor deems information revealed to be relevant to the member’s fitness or ability to fulfill his/her position, the counselor may disclose the information to the person in authority over the member. Authorized staff may also have limited access to your pastoral file. Any other person seeking access to your pastoral file may do so only with your written permission. However, Mosaic Church cannot guarantee complete confidentiality with regard to the information received from you.

APPOINTMENT GUIDANCE

Children: Unless your child is receiving ministry, please DO NOT bring children with you to your session. Due to safety concerns, your children cannot be left unattended in the reception area during your session and due to the sensitivity of the topics being addressed, we do not feel that it is the best interest of the child for him/her to be present in the room during the session.
Cancelation: The care seeker agrees to provide at least 24-hour notice when canceling an appointment by contacting the church office. Failure to do so could result in the termination of future appointments. Late arrivals past 15 minutes will be canceled.
Right to Refuse Services: We reserve the right to refuse service to any person/persons whose behavior demonstrates a threat to the physical and/or emotional safety of Mosaic staff or volunteers. We will also decline ongoing counseling if the individual/couple are not willing to consider and apply the recommendations provided by the counselor.

I have read and agree with the above statements regarding Services, Appointments and Rights/ Acknowledgement *

As the care seeker, I have read, addressed any questions, and received clarification to a level of satisfactory understanding and agree to abide by all contents of this Biblical-based Counseling Services Agreement. I agree to release Mosaic Church, its pastors, employees, volunteers, and counselors from all liability and any claim or litigation associated with my counseling sessions and the Counseling Team and I consent to participate in counseling with the assigned Biblical counselor.

Please type your full legal name below to acknowledge receipt and serve as your electronic signature *