Please complete this form in its entirety. Items with an asterisk (*) are required. First Name*
Last Name*
Email*
Phone*
Address*
Gender* Birthday (including year)*
Are you open to online counseling through a confidential zoom room we provide?* Highest level of education*
Degree?* What is your degree in?
Employer*
Occupation
Marital Status:* Referred to The Hope of Denver or Grace Chapel by:
Why do you desire to meet with a biblical counselor?*
What significant events occurred in your life/family's life when this issue began?
What have you done on your own to resolve this issue already?*
How would things be different for you if the issue were remedied?*
What results are you hoping to gain from biblical counseling?*
Personality Data
Check any of the following words that best describe you now.
Other words that describe you:
Complete the following sentences.
People that know me think I am:
If they knew the "real me" they would know that I am:
What I desire more than anything else in life is:
What I fear most in life is:
Is there is any other information about your personality that would be helpful for us to know?
Please check any of the following that currently apply.
PHYSICAL ISSUES EMOTIONAL ISSUES LIFESTYLE/CHOICES ISSUES Health Information
Rate your health Have you had any health changes in the last two years?* What changed?
List all important present or past illnesses, injuries, or disabilities:
Date of last medical exam Were there any issues of significance addressed by your doctor in this exam? What issues were addressed?
Are you taking any medications?* Please list medications by name, dosage strength, frequency, and reason taking.
Do you use any recreational drugs?* Please disclose:
Have you ever had any counseling before?* When were you in counseling last?
MM slash DD slash YYYY
For how long?
What were the circumstances that led you to seek your last counselor, and what was the outcome?
Are you willing to sign a release that would allow your counselor and medical doctor to talk if needed? Religious Background
Do you attend a church?* What church do you attend?
How often do you attend church?*
How would you describe your relationship with God?
How frequently do you read the Bible? Marriage and Family Information, if Applicable
Spouse's name:
Spouse's Phone:
Is this your emergency contact? Emergency contact info:
Provide the name and contact info for your emergency contact.
Date of marriage: Husband's age when married:
Wife's age when married:
Is your spouse willing to come to counseling? Have you previously been married?* Provide the dates from _____ to ______ of any previous marriage(s)?
How did the previous marriage terminate? Information About Your Children
Please provide the name, age, sex, marital status, and note PR* if applicable:
* PR = child from a previous marriage/relationship.
Anything else you believe would be helpful for your counselor to know:
Registration and Informed Consent
We welcome you to The Hope of Denver Biblical Counseling Center, a ministry of Grace Chapel. We desire to be used by God to speak His truth in love. We know that the path to maturity is often steep and rough; at times, it is filled with pain and confusion. However, there are answers and practical ways you can find hope. We believe that the Bible is God’s all-sufficient guide for living. We believe that Jesus Christ is the way, truth, and life and by the power He provides us, we can find freedom and peace when facing non-organic life issues.
As we start our counseling journey with you, we think it is important that you understand our philosophy of counseling, who we are, and what we are committing to you. We are not asking that you agree with all of the following information, we just ask that you acknowledge you have read it and understand our practices.
This information is provided so that you understand the conditions for participating in our Biblical Counseling Center Ministry. Please read this carefully and be prepared to ask questions about anything that seems unclear when you meet with your counselor.
I have read, understand, and agree to information provided* The Hope of Denver Biblical Counseling Center provides insight and instruction based solely on the Bible. Our ministry focus and purpose is to address spiritual and heart issues by short-term, goal-based, Bible-based counseling provided by the Grace Chapel pastoral staff and The Hope of Denver Biblical Counseling Center counselors. When we use the term “biblical counseling,” we are referring to counseling as intensive discipleship, trusting that the Bible has what we need to address and solve life’s problems. Our free Counseling Ministry is a way we can “love one another” as the Bible tells us to do (John 13:34).
I have read, understand, and agree to Ministry Focus* When serving in The Hope of Denver Biblical Counseling Center Ministry, our counselors provide biblically-based, spiritual insight on issues discussed. Our counselors are certified or pursuing certification with the Association of Certified Biblical Counselors. While some of our counselors may be licensed therapists with the State, or serve as doctors, lawyers, or have other advanced training, when serving in our ministry, they are helping you solely as a biblical counselor. We believe the Bible is sufficient for life and living and use it as the basis for all counseling we provide. Although our counselors may be licensed or skilled in other areas, when they are serving at The Hope of Denver Counseling, they do not provide the same type of professional services as when they function professionally outside the church.
I have read, understand, and agree to We Serve as Biblical Counselors, Not as State-licensed Professionals* The Hope of Denver Biblical Counseling Center is overseen by Grace Chapel
The Hope of Denver Biblical Counseling Center Ministry is a part of Grace Chapel’s ongoing service to South Denver. All we do here submits to the authority of the Elders and is doctrinally aligned with Grace Chapel. We believe the Church of Jesus Christ should provide counseling because He holds the answers for life.
I have read, understand, and agree to The Hope of Denver Biblical Counseling Center overseen by Grace Chapel* Appointments
We believe that your time is important. We also believe that work done in this ministry is a matter of stewardship. We ask all participants, seeking biblical counseling, to be seen by appointment only. Please use proper means of contacting your counselor, respecting their own time and not taking advantage of your access to him or her. If you have scheduled an appointment and cannot attend, you must notify us twenty-four (24) hours in advance, so someone else needing care may be scheduled for that appointment time.
I have read, understand, and agree to Appointments* Improper Conduct
Sexual behavior, of any kind, between the counselor and a counselee is never appropriate. Any inappropriate sexual or physical intimacy shall be reported immediately to the appropriate supervisor of The Hope of Denver Biblical Counseling.
I have read, understand, and agree to Improper Conduct* Resolution of Difficulties
On rare occasions, a conflict may develop between an individual and The Hope of Denver Biblical Counseling Center. To ensure the conflict will be resolved in a biblically and faithful manner, we require all individuals to agree that any dispute will be settled by mediation and legally-binding arbitration, if necessary. This is in accordance with the Rules of Procedure of the Institute of Christian Conciliation.
I have read, understand, and agree to Resolution of Difficulties* Confidentiality
Confidentiality is an important aspect of the counseling relationship. We will carefully guard any information you entrust to us. All communication between you and your counselor will be held in strict confidence unless you or a parent, in the case of a minor, give authorization to release this information.
The exceptions to this would be:
1. If a person expresses intent to harm himself/herself or someone else.
2. If a sexual advance is made or the counselee asks the counselor to violate any element of the Association of Certified Biblical Counselors Standards of Counseling.
3. If there is evidence or reasonable suspicion of abuse against a minor child, elder person, or dependent adult.
4. If a subpoena or other court order is received directing the disclosure of information.
5. If our biblical counselors are consulting with their supervisor.
6. If a person persistently refuses to renounce a particular sin (habitual, unrepentant rebellion against the Word of God), and it becomes necessary to seek the assistance of others in the church to encourage repentance, restoration, and reconciliation (see Matthew 18:15-20).
Please be assured that our counselors prefer not to disclose personal information to others, and that they will make every effort to help you find ways to resolve a problem as privately as possible.
I have read, understand, and agree to Confidentiality* Agreement to Not Subpoena
I agree, acknowledge, and affirm that I am requesting biblical counseling as it pertains to an issue in my life. I will not, under any circumstance, have my counselor or other representative of The Hope of Denver Biblical Counseling, be subpoenaed or require them to appear in court for a legal suit regarding matters disclosed or discussed during the course of my participation in this religious ministry.
I have read, understand, and agree Not to Subpoena* The Use of Homework Between Sessions
As a general practice of biblical counseling, our counselors will often give work to be done by the counselee, at home, between sessions . We believe that true change comes when the issue is addressed in and outside of our sessions. We ask that you take the homework seriously. If you return to counseling sessions without completed homework, that will be discussed with your counselor. If it happens repeatedly, your counseling sessions may be terminated until the work, at home, can be done in an intentional and timely manner.
I have read, understand, and agree to Homework between sessions* Requested Commitments from Each Counselee
We ask that you commit to the following while in counseling at The Hope of Denver Counseling Center:
• Honestly and openly share your hurts and struggles.
• Evaluate your own emotions, actions, motivations, beliefs, and relationships.
• Participate in the growth of renewed emotions, actions, convictions, and affections.
• Come to each session prepared to review your progress throughout the previous week (including the completion of personalized “homework” assignments) and prepared to share your goals for the present session.
• Attendance at Grace Chapel, or at one of our approved local partners.
I have read, understand, and agree to requested commitments from each counselee* Questions
Having read ALL information fully and completely, I agree to discuss any questions I have with the biblical counselor.
I have read, understand, and agree to discuss my questions with my biblical counselor* Is the person being counseled under the age of 18
NOTE: All counselees that are under the age of 18 will require the parent or legal guardian sign a Consent to Minister to a Minor form.
I attest that the information provided in this form is both accurate and truthful.*
I understand that the counseling I will receive will be by a biblical counselor that would represent himself or herself as a Colorado State non-licensed therapist, and the biblical counselor will be operating under the umbrella and accountability of the Grace Chapel Elders and Standards of Conduct for The Hope of Denver Biblical Counseling Center.
By typing your name below, you certify that you agree with all statements and conditions provided above.*
Submitted this Date* 