Biblical Counseling Center Of Okanogan

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Biblical Counseling Center Of Okanogan

“The Light shines in the darkness, and the darkness has not overcome it.” John 1:5

There are times in our life when we struggle. We all have times like these (John 16:33). We commend your wisdom in seeking help when needed, since “Plans fail for lack of counsel, but with many advisers (counselors) they succeed” Proverbs 15:22. We consider it a privilege to assist you during this time in your life. In order for us to do this effectively, we need to know something about you and your situation. This application helps to serve in this endeavor. Please fill out this form completely and honestly. Do not leave anything blank, and please do not be cryptic. The more information we have, the greater our ability will be to help you. Remember, all of this information will be kept in strict confidence. Please use a separate piece of paper to fill out the questions at the end or if additional space is needed for any other questions. Once we receive your completed application, we can begin to schedule appointments. We cannot begin the counseling process without this form returned to us first. “He who gives an answer before he hears, it is folly and shame to him.” Proverbs 18:13. If you have any questions, please feel free to give our office a call at (509) 486-8888 during regular business hours.

An incomplete application will not be processed. Please return this form via mail, email, or fax:

The Father’s Ranch/B.C.C.O. P.O. Box 1352

Tonasket, WA. 98855 (509) 486-1543 (fax)

[email protected] Thank you. The B.C.C.O. Counseling Staff


Biblical Counseling Center Of Okanogan

Application

I. IDENTIFICATION DATA Date: ____________________

Name: __________________________________________________________________

Spouse’s Name (if married): ________________________________________________

Email Address: ___________________________________________________________

Personal website/blog/social networks:

Home Telephone: ____________________ Cell Phone: ______________________

Current Address: _________________________________________________________

If this is a temporary address, please explain and provide your permanent address:

Business Phone: ______________ Birth date: _____________ Age: ______ Sex ______

Marital Status:

If married, is your husband in agreement with you applying to TFR?


Please describe your current living arrangements:

Education (last year completed):________ (grade)

Degrees: ________________________________________________________________

Occupation: _____________________________________________________________

Employed By: _______________________________ For How Long: ______________

Other training (list type and years):

Referred here by: _____________________________ Relationship: ________________

Address & Phone: ________________________________________________________

Is anyone requiring you to seek counseling (e.g. court system, Church elders, family

member, etc.)? If “yes”, please explain:

Have you applied to BCCO or any TFR program in the past? If “yes”, please provide the date, the program name, explain the outcome, and whether or not you participated in our program:


II. HEALTH INFORMATION

Current Height: _____________ Current Weight: ______________

Rate your health:

Have you experienced any significant weight changes recently?

If yes, please answer the following questions: Lost: _______ Gained: _______

List all important present or past illnesses, injuries, surgeries, or handicaps:

Date of last medical examination:_______________

Your physician: ___________________ Address: _______________________________

Report:

How many hours of sleep do you average each night? _________ Is it restful?

When do you go to bed? _________ Fall asleep? _________

If there is a length of time between going to bed and falling asleep, what do you do

during that time?


When do you wake up? _________ Get out of bed? _________

If there is a length of time between waking up and getting out of bed, what do you

do during that time?

Describe any recent changes in sleep patterns:

How energetic do you feel most of the time? ___________________________________

Please list any medications or supplements you are presently taking:

Medication Dosage Purpose For How Long


Please list all substances you have used, including prescription/non-prescription drugs used for other than medical purposes, prescriptions not prescribed to you, illegal drugs, alcohol, marijuana, cigarettes, and any other substances.

Substance Frequency of Use Date Began Using

Date Last Used

Currently Using?

Please provide any additional information about the items on the above list:

Longest period clean: __________________ Maximum habit cost per day: ___________

What is your average daily caffeine consumption including coffee, tea, chocolate, soft drinks and other stimulants?


Have you ever had a severe emotional upset? If “yes”, please explain:

Have you ever intentionally cut on yourself or engaged in any form of self-harm? If “yes”, please explain in detail, why, when and how:

Have you recently suffered the loss of someone who was close to you? If “yes”, please explain:

Have you recently suffered loss from serious social, business, or other reversals?

If “yes”, please explain:

Have you ever been hospitalized for emotional or behavioral problems?

If “yes”, please explain when, where, and what for:


Have you ever been in residential counseling?

If “yes”, please state where, when, and why, and the reason you left:

Have you attended support groups (e.g. AA) or group counseling?

If “yes”, please explain

Have you ever tried to commit suicide?

If “yes,” when and how many times have you attempted?

How much time do you spend on the Internet each day? __________________________

How much time do you spend on social media sites? ____________________________

How many text messages do you send/receive each day? __________________________

Is your diet supplemented or restricted in any way? If “yes”, please explain:


What type of food do you normally eat (e.g. healthy/unhealthy/dining out/home cooked/diet/etc.)?

Have you ever had an eating disorder? If “yes”, what and for how long:

Do you exercise regularly? If “yes”, doing what, how often, and for how long?

Are you sexually active? If “yes”, since what age? _______________________

Sexual Preference:

Have you ever been involved in a homosexual experience? If “yes”, please explain:

Have you ever struggled with pornography? If “yes”, what and for how long?


At what age were you first exposed to pornography? ___________________

Have you ever been abused sexually or physically? If “yes”, please explain:

Have you ever abused anyone sexually or physically? If “yes”, please explain:

Have you ever been involved in prostitution? If “yes”, please explain:

Have you ever contracted an STD?

If “yes”, please explain, and include whether or not you have a current infection:

Do you struggle with any other addictions (gambling, overworking, shopping, romance,

hoarding, sports or hobbies, OCD, TV, etc.)? If “yes”, please explain:


Do you struggle with any of the following? (Please mark all that apply and provide an explanation below.)

Mood Swings People Pleasing Isolation/Withdrawal Memory Loss Anxiety Panic Attacks PTSD Bitterness Physical Violence Aggression Angry Outbursts Quiet Simmering Anger Depression Co-Dependency Fantasizing/Daydreaming

Please explain each item you marked:

III. FINANCIAL INFORMATION

Are you paying child support? If “yes”, please explain:

Do you have any outstanding bills or debt? If “yes”, please explain:

Are you receiving government assistance? If “yes”, what, why, and for how long:


IV. RELIGIOUS BACKGROUND

Denominational preference: _________________________________________________

Are you a member or regular attender of any Church?

If “yes”, where and for how long?

Pastor’s Name: ________________________________ Phone: __________________

Have you communicated to your Church leadership (e.g. Pastor, Elder, Deacon, etc.) that

you are applying for counseling?

If “yes”, please provide the name, title, and phone number of the person you

notified: ___________________________________________________________

Church attendance per month:

Church attended in childhood and the denomination: _____________________________

Have you been baptized? If “yes”, what was your age? _________________

What is your spouse’s religious background (if married)? _________________________

Do you consider yourself a religious person?

Do you believe in God?

Who do you believe God to be?

Do you pray to God?

What do you pray about?


Are you saved?

How often do you read the Bible?

Do you have regular devotions?

If “yes”, how many times per week do you have personal devotions? ___________

Family devotions? ______________

Are you involved in any ministries or community service? If “yes”, please explain:

Have you ever been involved in a cult or exposed to their teaching (e.g. Christian

Science, Scientology, Brotherhood, Mormonism, Jehovah’s Witness, Eastern

Religions, etc.)? If “yes”, please explain:

Have you ever participated in occult activity (e.g. scientology, séances, Satanism, new

age, out-of-body experiences or trances, cults, mediums/channelers, Ouija board,

tarot cards, divination, witchcraft/Wicca, sorcery)? If “yes”, please explain:

Explain recent changes in your religious life, if any:


V. PERSONALITY INFORMATION Have you ever had any psychotherapy or psychological counseling before?

If “yes”, list your counselor(s), therapist(s), therapies and dates:

What was the outcome?

Are you willing to sign a release of information form so that your counselor may write

for social, psychiatric, or medical reports?

Parents (mark all that apply):

Never Married Married Separated Divorced Remarried

Your age when parents separated: ________ Your age when parents divorced: ________

Who raised you (e.g. married parents, mom only, dad and step mom, guardian, etc.)?

How many older brothers____________ sisters______________ do you have?

How many younger brothers ____________sisters______________ do you have? (Please indicate if siblings are step siblings)

Have you ever lived in a foster home?

Are you an adopted child? Age when adopted: ________________


Mark any of the following words which best describe you now:

Are there any others you might add? __________________________________________

Please mark each item that you have experienced:

Felt people were watching you People’s faces seemed distorted

Colors seem too bright Colors seem too dull

Unable to judge distance Hearing is exceptionally good

Hallucinations Afraid of being in a car

Have you ever been arrested? Incarcerated?

Under a restraining order? On probation or parole?

Any pending court dates? Current warrants?

If “yes” to any of the legal questions, please explain dates and reasons:

Active Nervous Moody

Ambitious Hardworking Often-blue

Self-confident Impatient Excitable

Persistent Impulsive Likeable

Leader Quiet Hard-boiled

Submissive Sensitive Lonely

Self-conscious Unstable


VI. MARRIAGE & FAMILY INFORMATION

Name of spouse (if married): ________________________ Your spouse’s age: _______

Spouse’s education (in years): _______ Spouse’s occupation: _____________________

If you and your spouse don’t currently reside in the same residence, please explain:

Date of marriage: ______________ Your ages then: husband ________ wife ________

How long did you know your spouse before marriage? __________

Length of steady dating with spouse: ____________ Length of engagement: __________

Has husband been married before? If “yes”, how many times? ________

Has wife been married before? If “yes”, how many times? __________

Have you ever been separated? If “yes,” when:

Has either of you ever filed for divorce? If “yes”, when?

Give brief information about any previous marriages including how/why they ended:


How would you describe your sexual relationship:

Are you in marriage counseling right now? If “yes”, what is the name and

phone number of your counselor? _______________________________________

When did you begin counseling? _____________________________________________

Is your spouse willing to come in for counseling?

Please complete for your children and step-children:

PM* Step** Name Age Sex Living? (Yes/No)

Education in Years

Lives with you

*Check this column if child is by previous marriage **Check this column if child is your stepchild Who has custody of your children? ___________________________________________

Which of your children are married?


Other Pregnancies: # of miscarriages: __________ # of abortions: ____________

Are you pregnant? If “yes”, when are you due? __________________

Has a doctor confirmed your pregnancy?

Who is the father and what is your current relationship?

What are your plans for your child (e.g. single parenting, adoption, etc.)?

I think I could have other children that I haven't met... (men only)

If “yes”, please explain:

VII. BRIEFLY ANSWER THE FOLLOWING QUESTIONS

1. What is your main problem? (What brings you here?)

2. Describe your relationship with your spouse (if married).


3. Describe any adulterous affairs by you or your spouse (if married).

4. What other personal problems or complicating factors are affecting your life and/or marriage?

5. When did your problem(s) begin? (List dates if possible)

6. What have you done about it?

7. What led you to seek help?


8. What can we do? (What are your expectations in coming here?)

9. If you are saved, please describe how you know Jesus as Lord and what changes occurred in your life after becoming a Believer.

10. Describe your past and present relationship with your father and mother (Do this for each one). Include the things that stand out in your memory about your parents when you were a child and how your views have changed in adulthood.

11. How would you describe your relationship with God?

12. How would you describe your spouse’s relationship with God (if married)?


13. What are you willing to do to resolve your problem(s)?

14. Is there any other information we should know?


VIII. COMMITMENT & DEDICATION The Father’s Ranch Ministries provides Biblical counseling to glorify God and help you with your specific needs. Our counseling is distinctly Biblical, and our counselors are certified through the Association of Certified Biblical Counselors (www.biblicalcounseling.com). TFR’s counselors are not mental health professionals or psychotherapists, and they do not follow such methods. They are not certified through the State of Washington. We believe that God's Word is totally sufficient for every need, trial, or problem, and it is the change agent that renews the mind and subsequently changes behaviors (2 Tim. 3:16-17; Rom. 12:2). Therefore, any counsel given will be in line with Biblical principles with the Scripture as the final authority. Our counseling is not infallible, nor do we pretend to know all there is to know about Biblical teaching and its applications to life. However, we are well equipped and competent to help people change. We will make a point to differentiate between God’s commands and our suggestions. We may, at times, seek assistance from other trained counselors in their specific area of experience. Please note that we do not give medical or legal advice. We have three requests of you. First, we ask you to be honest and teachable. It is very difficult, if not impossible, to help you if you lie to us or are not willing to receive instruction. Secondly, we ask you to commit to doing homework assignments that will encourage lasting change. These assignments are not academically strenuous, but are used to reinforce and teach that which has been exposed in our time together. Thirdly, we ask you to be patient. Habits were not developed overnight, and new habits will take time to develop as well. If you are not sure if you will be interested in Biblical counseling, you have the option of attending one or two sessions to discover what Biblical counseling is like. If you are unwilling to use the Bible as the final authority in counseling or unwilling to do the homework assigned, sessions will be terminated. At any time the counselor or the counselee has the option of terminating counseling for any reason. As a rule, counselee confidentiality is maintained; however, the State of Washington requires that information of confessed criminal behavior must be reported to the appropriate civil authorities. In such cases, confidentiality cannot be maintained. Furthermore, Biblical mandates require that occasionally the leadership of the counselee’s Church may need to be brought into the counseling and/or restoration process (Matthew 18:15-17; 1 Corinthians 5:9-13; Galatians 6:1-2). We will only disclose information to your Church leadership which we believe is necessary for them to effectively and Biblically fulfill their responsibility to shepherd you. Additionally, information may be shared with your spouse as needed (Matt. 19:4-6), or to assist a husband in leading his wife (Eph. 5:22-33). Again, in such cases, no promise of absolute confidentiality can be assured. We do ask our clients to contribute financially to their counseling or ask their Church to help with the expense. Please view our website for counseling fees for each of our programs. If you are interested in counseling with The Father’s Ranch Ministries, please sign below. I have read the conditions for counseling set forth in this Informed Consent Form. I agree to be honest, teachable, and give my best effort to completing the assigned homework. I understand I am held fully responsible for how I implement the counseling I receive. I also understand and agree with the policies of confidentiality. I affirm that all of the information on this application is true and correct. Signature: ______________________________________ Date: __________________________

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Biblical Counseling Center Of Okanogan