ONLINE COUNSELING FORM

COUNSELING INFORMATION AND CONTRACT

Diagnostic Tools:

I use helpful counseling forms such as this Personal Data Information Form, the Problem Pattern Analysis form, and other aids to gain an understanding of the central problems a person is experiencing.

Intent Listening:

I encourage the counselee to speak/write his mind/thoughts in an appropriate fashion and to discuss his thoughts, anxieties, resentments, and fears so that the counselor will have a clear understanding of the central problems.

Team Counseling:

There are times when a counseling situation may call for a team approach. In this event, I may have your local minister involved in the counseling. The counselors share insights and opinions with one another which pertain to the case. Team Counseling can be especially helpful when counseling Online.

Assignments:

The counselee will make more rapid progress when they are required to study or to perform specific informational or behavioral assignments which pertain to the problem. I tailor these assignments to the individual counselee and the circumstances. Having your local minister involved in the counseling will aid with this progress.

Accountability:

I am not interested in wasting the time of the counselors or the counselees. I am interested in believers learning how to experience the peace and joy that result from a walk of obedience to God's Word, and I will hold the counselees accountable for doing the assignments on schedule.

 

ABOUT CONFIDENTIALITY

I am careful to protect each counselee's confidentiality. There are times, however, when a counselor must consult with other counselors for advice. If information is revealed in counseling which indicates a genuine potential for harm to a counselee or others, the counselor may have to share that information with the appropriate authorities or family members.

 

Your First Step:

Fill in ALL of the information in the Counseling Request Form below. 

NOTE- It is very important that you follow instructions and be sure you complete ALL of the Personal Contact Information and answer ALL of the Questions 1 thru 7 completely with details.

 

Counseling Request Form
(Basic Information)

Name (REQUIRED)

E-Mail (REQUIRED)

Phone (REQUIRED)

Your Personal Contact Information - Complete ALL Information:
Address

City
State
Zip Code
Country
Fax

Sex
Age
Marital Status
Occupation
Height
Weight
Health Condition

Your Local Church
Your Local Minister's Name
Your Local Minister's Phone
Your Local Minister's E-mail

Problem Check List - Check those which are CURRENT:
Anger
Anxiety
Apathy
Bitterness
Change in Lifestyle
Children
Depression
Deception
Envy
Fear
Gluttony
Guilt
Health
Homosexuality
Impotence
In-laws
Appetite
Memory
Moodiness
Rebellion
Sex
Sleep
Hearing
Wife Abuse
Smoking
Drinking
Drugs
Gambling
Pornography
Lying, not telling the truth
Any Vice

Other Explained Below
Enter Other Problems Below:




Answer all of the following questions completely.

1. Enter - What is your problem? Below:

2. Enter - What have you done about it? Below:

3. Enter - What can we do? (What are your expectations?) Below:

4. Enter - Is there any other information we should know? Below:

5. Enter - Have you ever had any therapy or counseling before? Explain Below:

6. Enter - Are you presently taking any form of medication? List Below:

7. Enter - Describe your religious background and spiritual outlook? Below:

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Biblical Counseling by Ed Healy
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