PDI Form for Placerita Bible Church

Completed: 0%

Note: If a question on the form does not apply, please leave it blank.

Name

Address

Address Line 2

City

State/Province

Zip/Postal Code

Primary Phone

Secondary Phone

Email * This will allow you to receive a copy of the completed form.

Referred By

Birth Date (MM/DD/YYYY)

Gender: Male Female

Completed Education

Marital Status

Employer

Position

Years at Employer

Is English your first language?
Yes No If not, what is?

Completed: 12%

What is the main problem, as you see it? What brings you here? - required

What have you done about the problem? - required

What are your expectations in coming for counseling? - required

Is there any other information that we should know?

Does anyone from your church plan to accompany you to counseling? Yes No

If Yes, please indicate his/her name(s), and the nature of your relationship with them.

Completed: 24%

Spouse

Birth Date (MM/DD/YYYY)

Occupation

Years at Employer

Primary Phone

Secondary Phone

Email

Date of Marriage (MM/DD/YYYY)

How long did you date?

Circumstances of meeting and dating (brief)

Is your spouse willing to come for counseling? Yes No If not, please explain

Is your spouse in favor of your coming? Yes No If not, please explain

Have either of you been previously married? Yes No If so, to whom?

Have you ever been separated? Yes No

Have you ever filed for divorce? Yes No

If there have been multiple marriages, briefly explain time frames, children involved, and reasons.

Information About Children:

Additional Children (separate information with commas, one row per child.)

Describe your relationship to your parents

Number of Siblings

Birth order of all siblings

Did you live with anyone other than your parents growing up?

Are your parents living? Do they live locally?

Completed: 36%

Describe your health

Do you have any chronic conditions (pain, headaches, insomnia, etc.)? Yes No If so, what:

List important illnesses and injuries or handicaps

Approximate Date of last exam:

What was the report?

Physician's name and address

Current medication(s) and dosage

Have you ceased taking any drugs recently? Which ones, why, and when?

Have you ever used drugs for anything other than medical purposes? Yes No If so, explain

Have you ever been arrested? Yes No If so, why, when, and was there a resulting sentence?

Do you drink alcoholic beverages? Yes No If so, how frequently and how much

Do you drink coffee? Yes No How much?

Other caffeine products consumed

How much?

Do you smoke? Yes No What: Frequency:

If you have ever had interpersonal problems on the job, please describe them

Have you ever had a severe emotional upset? Yes No If yes, please explain

Have you ever seen a psychiatrist or counselor? Yes No If yes, how was it helpful? Please explain

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records? Yes No

Completed: 48%

Denominational Preference

Church attending I am a member

Location

Pastor's Name

Pastor's Phone Number

Do we have permission to contact your pastor? Yes No If not, please explain why: * Permission to contact your pastor includes sharing information on this PDI.

Church attendance per month:

Do you believe in God?     Yes    No
Do you pray?     Yes    No
Would you say that you are a Christian?     Yes    No    Or interested in becoming a Christian:     Yes    No    Have you ever been baptized?     Yes    No

How often do you read the Bible?

Explain any recent changes in your spiritual life

Completed: 60%

Have you had any menstrual difficulties: Yes No

If you experience tension, tendency to cry, other symptoms prior to your mestrual cycle, please explain

Have you ever had an unplanned pregnancy? Yes No

Have you ever had an abortion? Yes No

If you had an abortion, did you suffer any medical side-effects that would be helpful for your counselor to know?

Completed: 72%

Please select areas you are struggling with.

Completed: 84%

Before Beginning Biblical Counseling

In order to make our first session as profitable as possible we would ask you to give careful attention to the following items. If you have difficulty in completing any of the following steps, please call 661-259-2913 and we will be glad to answer any questions you might have.

About Biblical Counseling

The biblical counselor is trained in the meaning and use of the Bible and biblical principles for counseling. He is committed to the position that Scripture provides the only authoritative guide for what we are to believe and how we are to live. He will not base his counseling knowledge on his own opinions, experience, or concepts of behavior, but will seek to apply the full range of biblical truth into focus on the counselee's need.

The biblical counselor deals with a wide range of problems, including broken marriages, parent-child relationships, fear, depression, alcohol and drug abuse, tension, anxiety, worry, and other problems resulting in mental and physical challenges.

Since we are both a counseling and a training center, we often do biblical counseling in teams. Normally sessions are conducted with a lead counselor and one or two assistant counselors in attendance. You will find them courteous, factual, and efficient. Confidentiality is respected but held within appropriate limitations. A case may be discussed with other counselors or other professionals, but only to the degree necessary to find further biblical solutions to the problem. All such consultation is conducted in accord with the highest standards of biblical ethics.

Biblical counselors believe in the total health needs of the counselee. Your counselor may recommend that you have a full or specified medical examination. If medical assistance is required, counseling will continue whenever possible.

Your counselor will use all of his skill in applying biblical principles to help you in whatever problem deprives you of the peace and joy that God has promised to you in His Word. Your counselor will concentrate on three basic foundations from God's Word:

Hope — In Jesus Christ we have a great High Priest who has been tempted in all things, yet without sin. Thus, because of Him, even though every sin common to man may be tempting you, God has promised that He will not let you be tempted beyond your endurance, but will provide for you the way to escape from sin so that you can endure it (1 Cor. 10:13; Heb. 4:14-16). The Scripture also reminds us that in God we may abound in hope (Rom. 15:13).

Change — In Christ we can learn how to lay aside the old selfish ways of living and put on the new ways of living in a manner worthy of the Lord, to please Him in all respects (2 Cor. 5:9), bearing fruit in every good work and increasing in the knowledge of God (Eph. 4:20-24; Col. 1:10).

Practice — In Christ we must become doers of God's Word, lest we be merely hearers, forgetting and deluding ourselves. Only in effectual practice of the Scripture shall we be blessed in what we do, and only then will we please the Lord (James 1:22-25, Mt. 7:24-27).

In order to achieve lasting victory over the problems of life, it is vital that each person becomes established in a consistent Christian walk. The Lord has provided the local church to help in this process (Heb. 10:24-25). Therefore, it is important that counseling sessions be accompanied by church activities that encourage discipleship and fellowship. For this reason, the PBC elders desire that you make every effort to attend, as a minimum, one worship service every week. If you are part of a Bible based church your counseling team may contact your church and request their assistance with this. It is our commitment to do what will best bring about the victory you can experience over your problems.

Session Details

Normally, counseling sessions will last one hour each week and will continue for eight to ten weeks. If you respond quickly to biblical counsel the number of counseling sessions may be lessened. However, if the counselor does not observe definite change in the first few weeks, he will seek to identify the cause of the failure, discuss it with you, and help you to correct it.

Your first appointment will be arranged by one of the administrators within 48 hours of receiving your completed Personal Data Information (PDI) form. Subsequent appointments are to be confirmed with your counseling team. One of the assistant counselors will become your contact on any questions or matters requiring discussion between the actual counseling sessions. If you are unable to come to any of the counseling sessions, please notify your counselor at least 24 hours before the session.

You will need a notebook and your Bible at all sessions, including the first one. Be sure to bring them each time. Come with high expectations! You will find hope and encouragement even during your first session. From then on, with your cooperation, we are confident that you will find the true, good and acceptable answer to the difficulty that prompted you to come to us.

Consent and Commitment to Biblical Counseling

Our Goal — Our goal in providing biblical 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 enjoy fully His love for you and His plans for your life.

Biblical Basis — We believe the Bible provides guidance and instruction for faith and life. Therefore, our counseling is based on biblical principles rather than those of secular psychology or psychiatry. The counselors of this ministry are neither licensed as psychotherapists or mental health professionals. It should be understood that biblical counseling consists of the giving of biblical counsel and the practical application of the Bible to each individual. Yet, the counselee is held fully responsible for how he implements that counsel.

We are confident that the Bible has all of the information necessary for life and godliness (2 Pet. 1:3). There are no problems between people that the Bible fails to address either in general or specific principles. Our counselors are not infallible, nor do they pretend to know all there is to know about biblical teaching and its applications to life, but they are well equipped and competent to help people change. They will make a point to differentiate between God's commands and their suggestions.

Professional Advice — In the process of biblical counseling there are often times when there is a need for significant advice with regards to legal, medical, financial, or other technical areas. In those cases you will be encouraged by your counselor to seek independent professional advice. Our counselors will cooperate with such advisors and help you to consider their advice in the light of relevant biblical principles.

Confidentiality — Confidentiality is an important aspect of the counseling process and we will carefully guard the information you entrust to us. However, absolute confidentiality is not biblical; in certain circumstances the Bible requires that facts be disclosed to select others (Matt. 18:15ff). If your church leadership should inquire, we will disclose to them only that information which we believe is necessary for them to effectively and biblically fulfill their responsibility to shepherd you.

There are five situations when it may be necessary for us to share certain information with others: 1) when a counselor is uncertain how to address a particular problem and needs to seek advice from another pastor or counselor; 2) when a counselee attends another church and it is necessary to talk with his or her pastor or elders, 3) when there is a clear indication that someone may be harmed unless others intervene, 4) when a person persistently refuses to renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (see Matthew 18:15-20; Proverbs 15:22; 24:11) or 5) when criminal activity has been committed and the counselee refuses to bring the matter to the attention of local authorities. 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 — 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 as a result of counseling, will be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure of the Institute for Christian Conciliation; judgment upon arbitration award may be entered in any court having jurisdiction.

Termination of Counseling — It is our desire that the counseling arrangement will conclude with a healthy participation in a Bible believing local church and life contexts. However, at any time during the counseling process, the counselor or counselee, has the option to terminate the counseling arrangement.

Expectations and Commitments — As your counselor invests in you, he will also have some expectations of you. First, it is important that you be honest and be willing to trust your counselor. Second, your counselor will regularly send you away from each meeting with some homework. As the hard work of change happens more outside of the counseling meeting, this homework will be purposeful and necessary to work toward genuine and lasting change. Last, your counselor will be looking for a commitment of time. Problems and bad habits develop over long periods of time and often cannot be broken in a matter of days. For this reason, your counselor will be looking for a commitment to eight to ten meetings, held once a week. All meetings may not be necessary, but your counselor will seek to make that determination.

Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Jesus Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body.

Electronic Signature

I, (electronic signature required), have carefully read the conditions for counseling set forth on this page and agree to enter into counseling in accordance with them.

I am filling out this form on behalf of the counselee:

My Name

Relationship

Completed: 100%

Thank you for taking the time to fill out this form! Your complete and honest answers will aid the counseling process and allow the counselor to better understand you and your situation. We encourage you to review your answers. Once you click "Finish" an email will be sent to the counseling office at Placerita Bible Church. Please make sure your email address is filled in under the Personal section so you receive a copy of your PDI form.

If you have any questions about these guidelines, please contact the Placerita Biblical Counseling Center at 661-259-2913.

Click "Finish" to submit your Personal Data Inventory.