CCRS Marriage Counseling Information Sheet - Calvary Chapel Reno Sparks

Address *

Phone number *

Gender *

Birthdate *

What church do you attend? *

How long have you attended?

Occupation *

Education: Last grade completed (Prior to college) *

Other education: List type and years

Referred by and contact information

Marriage & Family Information

Name of spouse *

Phone number

Occupation

Spouse's birthday

Religion

Is your spouse willing to come in for counseling? *

Yes

No

Uncertain

Have you ever been separated? *

Yes

No

How long have you been married? *

How long did you know your spouse before marriage? *

How long did you date your spouse? *

How long was your engagement? *

Have you ever had marriage counseling? *

Yes

No

Are you currently seeing a counselor? *

Yes

No

Is there one problem which has motivated you to make this appointment? *

What are you expecting to receive from counseling? *

Is there any other information you think we should know?

On a scale from 1 to 10, how would you rate your marriage? *

min: 1 / max: 10

Ten meaning that you are very satisfied with your relationship.

Consent to Counseling

Our Goal:
Our goal in providing Christian counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to fully enjoy His love and plans for your life.

Biblical Basis:
We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of secular psychology or psychiatry. Neither the pastoral nor the lay counselors of this church are trained or licensed as psychotherapists or mental health professionals.

Confidentiality:
Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. However, there are five situations when it may be necessary for us to share certain information with others: when a counselor is uncertain of how to address a particular problem and needs to seek advice from another pastor or elder in this church; when a counselee attends another church and it is necessary to talk with his or her pastor or elders; when there is a clear indication that someone may be harmed unless others intervene; when a person persistently refuses to renounce a particular sin and becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation; or when a crime has been committed (see Proverbs 15:22; Proverbs 24:11; Matthew 18:15-20; Deut. 13:6-8). Please be assured that our counselors strongly prefer not to disclose personal information to others, and they will make every effort to help you resolve a problem as privately as possible.

Resolution of Conflicts:
On rare occasions a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts will be resolved in a Biblically faithful manner, we require all of our counselees to agree that any dispute that arises with a counselor or with this church as a result of counseling will be settled by mediation, and if necessary, legally binding arbitration. Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about these guidelines, please talk with a pastor or elder before your counseling appointment.

By submitting this form, you hereby acknowledge that Calvary Chapel of Reno/Sparks offers only Biblical counseling and discipleship designed to provide you with Godly counsel. Understanding this, the pastors at Calvary Chapel of Reno/Sparks are hereby released from any and all liabilities.

I have read and understand the above statement *