Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Are you an official member of Westminster?
*
Yes
No
Birthdate
MM
DD
YYYY
Gender
*
Male
Female
Prefer not to say
Marital Status
*
Never married
Separated
Divorced
Widowed
Married
Domestic Partner
Household Members
Health and Medical History
Please list any current medical conditions, medications, and/or supplements you are taking that may be relevant.
Check from the following list any items that you have experienced in the past 6 to 8 weeks.
If you are having a medical emergency please call 911
Family Background
Please provide a brief description of your family of origin and any significant events.
Please check any of the following that apply to you and/or your family
Life Patterns or Behavioral Concerns
Check any of the following that apply to you
What is your level of church involvement?
*
Minimal
Moderate
Very Involved
What role does faith play in your life?
*
Are you currently employed?
Yes
No
How much support do you have from people in your life?
No support
Minimal support
Moderate support
Strong support
Are there people you would like to invite to join you in your counseling sessions or process?
Have you had previous counseling experience?
Yes
No
Text Area
Is there interpersonal conflict in your life that is relevant to the issue(s) you would like to discuss?
What made you decide to pursue pastoral counseling at this time? What are your goals for counseling?
*
Who would you like to meet with?
Is there anything else you would like to let us know before you meet?
I agree to the following confidentiality agreement
*
The church is very sensitive to the issue of confidentiality. To release counseling information without your consent would violate both biblical standards and commonly accepted codes of counseling ethics. There are situations, however, where it may be required for us to share certain information with others. - Abuse or Neglect: We are committed to protect the vulnerable. Therefore, we will report to appropriate authorities if we believe a minor, elder, or person with disabilities to be at risk or that abuse or neglect has taken place. - Harm to self or others: We are called to protect life. Therefore, we will report to appropriate authorities if we believe a person to be at risk of life-threatening harm to self or others. - Public Health: We live in community and are called to responsible relationship with others. Therefore, we will participate in the reporting of relevant information to a public health authority when mandated by law and for general health oversight. - Legal Requirement: God has instituted authority for the establishment of justice and order. Therefore, we submit to legitimate requests for information needed for law enforcement purposes and also for the process of legal proceedings. We may occasionally seek consultation for our counseling. In these contexts, anonymous questions are asked and every effort is made to safeguard the identity of each counselee.
