Our Goal: To help you meet the challenges of life from a biblical, mental, emotional, and physical perspective.

Biblical Basis: We believe that the Bible provides wisdom for your life. Therefore, our counseling and mentoring is based on a Biblical worldview. Neither the pastoral staff nor the counselors of this church are trained as licensed psychotherapists or mental health professionals, nor should they be expected to follow the methods of such specialists. Pastor Bob is a Behavioral Life Coach Consultant and is credentialed as a Board Certified Pastoral Counselor through the American Association of Christian Counselors. Lay counselors and mentors are trained in biblical principles and complete continuing education courses through the American Association of Christian Counselors and their certified physicians and mental health professionals.

Not Professional Advice: Some of our counselors work in professional fields outside the church. When serving as counselors at Grace Fellowship, they do not provide the same kind of professional advice and services that they do when they are hired in their professional capacities. Therefore, if you have significant legal, financial, medical or other technical questions, you should seek advice from an independent professional or referrals from our resources. Our counselors will be happy to cooperate with such advisors and help you to consider their counseling in the light of a relevant biblical worldview.

Confidentiality: Confidentially is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. By law, there are certain situations in which information about individuals undergoing professional guidance may be released with or without their permission. These situations are as follows:

  1. Where children are physically abused, neglected, or sexually abused, the proper authorities must be notified.
  2. In emergency situations where there may be danger to the client or others, as with homicide or suicide, confidentiality may be broken.
  3. If a court of law issues a legitimate subpoena relating to a child abuse case, we are required by law to provide information specifically described in the subpoena.
  4. If an unreported life-threatening felony has been committed, we are required by law to report it to the police.

There are occasions however, when it may be necessary for us to share certain information with others:

  • When a person attends another church
  • When a person is under the care of other professionals

Please be assured that our counselors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible.

Resolution of Conflicts: If a conflict arises between a counselor and client, then the party suffering the offense should speak privately with the other party. If the conflict cannot be resolved in that forum, the party may request assistance from Pastor Bob Tome.

Having clarified the principles and policies of our Counseling Ministry, we welcome the opportunity to serve you. If you have any questions about these guidelines, please talk with the Counseling Pastor. If these guidelines are acceptable to you, please select "I agree" at the bottom of the form before submitting.

Name *
Name
Marital Status:
Address *
Address
Phone *
Phone
Did anyone direct you to us?
Last Grade Completed (Prior to College):
Name of Spouse:
Name of Spouse:
Spouse's Address (If different)
Spouse's Address (If different)
THE BASIC PROBLEM AS YOU SEE IT:
BRIEFLY COMPLETE THE FOLLOWING
INFORMATION ABOUT PRIOR COUNSELING
Have you ever had counseling before?
Counselor Name:
Counselor Name:
Counselor Name:
Counselor Name:
INFORMATION ABOUT PERSONAL HABITS & HEALTH
State of health:
Date of last medical examination:
Date of last medical examination:
Are you taking any medication(s)?
Have you used drugs for anything other than medical purposes?
Do you drink alcoholic beverages?
MARRIAGE & FAMILY INFORMATION
Name of spouse:
Name of spouse:
Spouse address:
Spouse address:
Spouse phone number:
Spouse phone number:
Is your spouse will to come with you?
Are you currently separated?
Since when have you been separated?
Since when have you been separated?
Have you ever been separated in the current marriage?
Has either of you ever filed for divorce?
If "Yes" when?
If "Yes" when?
Date of marriage:
Date of marriage:
Have you been married before?
CHILDREN INFO
Name of child:
Name of child:
Gender:
Name of second child:
Name of second child:
Gender:
Name of third child:
Name of third child:
Gender:
Name of fourth child:
Name of fourth child:
Gender:
SPIRITUAL JOURNEY INFORMATION
Church Address:
Church Address:
What type of relationship do you have with Jesus Christ?
PAST MEDICAL HISTORY
Do you have now or have you ever had any of the following:
Select all that apply.
FAMILY/SOCIAL HISTORY
Do you have a family history of:
Select all that apply.
Your personal habits:
Select all that apply.
EMOTIONAL HISTORY
Over the last 2 weeks, how often have you:
Over the last 2 weeks, how often have you:
Had little or no interest or pleasure in doing things?
Felt down, depressed or hopeless?
I have read, understand and agree to the terms and conditions as stated above. *