What We Believe
Mission and Vision
Missions and Outreach
Counseling/Member Care Request Form
We'd love to hear from you. Fill out the form below to get started.
Date of Birth (mm/dd/yyyy)
Preferred Method of Contact
Do you still live at home or under the care of a guardian?
If multiple people will be seeking care at the same time (group counseling, marriage counseling), please have each participant complete his or her own form.
If any questions that request a longer response are unclear, not relevant to your issue, or better discussed in person, feel free to submit a brief answer such as "unclear," "not relevant to issue," or "please ask in person."
Are you married or cohabitating?
Do you have any children?
Have you ever been divorced?
Are you a church member at Harbins?
What denominations or religions have you been involved with in the past?
Please note any significant changes in your religious life
Would you be able to join us for corporate worship during the duration of your care?
Since we believe that spiritual life comes through the ministry of the Word, we would prefer to have you join us for corporate worship. We also believe that the preaching of the Word and biblical counseling work together to help people see personal transformation.
Describe who God is:
Describe who Jesus Christ is:
Describe the kind of relationship you have with God and His son Jesus Christ:
In your own words, what is sin?
What is the definition of a Christian?
Describe your spiritual disciplines (Bible reading, prayer, fellowship) using specific descriptions (for example, how often do you read your Bible? How often do you pray? What habits and disciplines have you cultivated to help foster spiritual growth?)
What do you tend to pray about the most?
Highest degree level and school(s)
Employment (if applicable)
Please list where you work (address: street, city, state, zip code) and your job title
Length of Employment
How long have you worked at this location?
Please provide basic information about your work. Do you enjoy your work? What is the best part? Worst part? What is the greatest challenge you face at work?
Who did you live with growing up?
Describe your relationship with your father:
Describe your relationship with your mother:
Describe your relationship with siblings:
(include number and birth order)
Describe any significant events in your family life growing up:
Describe your general health (for example: eating habits, exercise):
Average number of nightly hours of sleep:
Do you have any chronic conditions or significant illnesses, injuries, or handicaps?
Have you ever seen a psychiatrist or psychologiest?
Please list any current medications and dosage:
Have you ever used drugs for anything other than medical purposes?
Please list current alcohol consumption (if any):
(# of drinks a day/week/month)
Please list current amount of caffeine consumption:
(# of cups per day/week/month)
Please list consumption of tobacco products:
(# of # a day/week/month)
We realize that problems cannot be fully represented through a checklist. This is our attempt to get a lay of the land so that we can more efficiently explore various areas of your life in order to help. If your problem is not listed here, please us the "other" category to write in your problem.
Change in Lifestyle
Pain (Chronic or Physical)
Same Sex Attraction
For every item checked above, please list a brief description of the problem, when the problem started, and other ways that you have sought to address this problem in the past:
From your current perspective, what is the cause of these problems?
Please list as many as apply. Answers may include: personal choices, spiritual forces, culture, nature/biology, upbringing/nurture, influence from close friends
How do use your free time?
(Hobbies, activities, friendships)
How much time per day do you spend on technology and media (outside of vocational uses of technology)? What type of games, apps, shows, or media do you watch/use/play?
Please try to be accurate with your media usage. If applicable, review your screen time on your mobile device.
Whenever you have free time or free mental space, what tends to occupy your mind? Where does your mind wander when nothing is occupying it?
Which people in your life know you the best? Which people do you feel the most comfortable to share your thoughts, feelings, and struggles?
Rate your current level of stress (1-low; 10-high). What are the greatest areas or auses of stress in your life?
How do you handle stress in your life?
What are the greatest areas of conflict in your life? How have you responded to these areas?
What are the most recent events which produced either guilt or shame in your life? How did you respond?
How do other people describe you?
Complete this sentence: Life is going the best when...
Complete this sentence: Life is going the worst when...
Complete this sentence: What I tend to worry about the most is...
Complete this sentence: Life would be better if...
Complete this sentence: If I could change one event from the past, I would change...
What are your expectations from counseling?
Is there any other information we should know?
NATURE OF COUNSELING AND COUNSELING AGREEMENT
Harbins Community Baptist Church offers biblical counseling from qualified and trained counselors from within the church's congregation. Each counselor will strive to offer Christ-Centered, Biblical Counseling, offering hope and help from Scripture to today's problems. We believe that the same God who made all things and plans every event and detail in our lives has spoken to us in Scripture. In Scripture, God has explained to humanity who we are as people, what is wrong with us, and how we can reconciled back to God and restored to our original image. Trusting in Scripture's sufficiency, each counselor will carefully seek answers from Scripture to your problems and help you apply God's wisdom to your life.
Unless otherwise stated, no counselor has received a state-license. We do not offer psychological or professional counseling or therapy. Our counselors will not offer medical, financial, or legal advice. Even though counselors may speak to medical, financial, or legal matters as far as Scripture addresses these matters, the counselee understands that no counselor is potentially liable for actions taken by the counselee in response to the counseling received at Harbins, since each counselee chooses how the counsel is applied to his or her life. If you have different expectations for your counseling than what has been described above, please let your counselor know at the onset of your counseling.
Counselors will be assigned to various cases based upon the nature of the counseling situation and the availability of counselors. It is not uncommon for multiple counselors or advocates to participate in a session. Both the counselor and the counselee reserve the right to end the counseling relationship at any time without explanation.
WHAT IS EXPECTED OF YOU?
It is our belief that change must begin with ourselves as we look to Jesus Christ for the power to change. Therefore, we ask you to approach the counseling and encouragement process as an opportunity for personal change and spiritual growth. We ask that you refrain from the temptation of focusing on others, and instead we ask you to focus on what changes God desires to make in your life, in the midst of your circumstances.
To increase the effectiveness of the counseling process, we ask the following of you:
1. Be committed to biblical counseling as described above.
2. Attend each scheduled session on time. Allow sixty minutes for most sessions, with a little more for the first session. If an emergency keeps you from attending, please contact the church office immediately.
3. Be as open and honest as you can. At the same time, each counselor realizes that talking about your problems may be very difficult for you and that trust and transparency may take time to develop.
4. Be patient—your problems did not develop in a day. It may take your counselor several sessions to get to know you and understand your situation. It is vital for him to listen carefully and gather thorough information.
5. In between sessions, complete the homework assignments given, and review and pray over the matters discussed during previous sessions. Counselors will give you helpful, doable assignments that fit our counseling aims. These are vital parts of the counseling process.
Confidentiality is an important aspect of the counseling process, and we will carefully guard the personal and private information you entrust to us as much as possible. We recognize the crucial importance of mutual trust within the counseling relationship. As a general rule, counselors will keep private the information shared within the counseling sessions.
At the same time, in light of biblical and civil law, we cannot guarantee absolute confidentiality in every situation. There are times when counselors or the pastors at Harbins might believe it necessary, at his discretion, to disclose otherwise confidential information to appropriate other people.
Some examples might include:
To ensure that you are receiving consistent counsel and support, your counselor might need to discuss your situation with appropriate leaders of our church or your home church. Counselors may seek help or feedback specific to different aspects of your counseling from other counselors. When sharing, counselors will exercise discretion in divulging personal information related to discussed issues.
If there is indication that you or someone else might be in danger of harm unless others intervene, the counselor might need to disclose information to civil authorities and to those in danger.
In cases of suspected child or elderly abuse or neglect, the counselor might need to report this to civil authorities. Also, if a court of law issues a legitimate subpoena relating to a child abuse case, we are required by law to provide the information specifically described in the subpoena
In counseling minor children or teens, the counselor may need to disclose information to parents or legal guardians.
In cases of unrepentant sin, the counselor may need to disclose information to other pastors to begin the process of church discipline.
Please be assured that we strongly prefer not to disclose your personal information to others and that we will make every effort to help you find ways to resolve problems as privately as possible.
We also ask you to agree not to discuss our communications with people who do not have a necessary interest in the counseling process. Where your situation might involve legal issues, you must agree to treat all dealings with your counselor concerning your case as settlement negotiations, which means they will be inadmissible in a court of law or for legal discovery. You must also agree that you will not try to force your counselor to disclose any information acquired during counseling or to force your counselor to testify in any legal proceeding.
In the highly unlikely event of a conflict between you and your counselor, all parties must seek to resolve it in a biblical manner, through discussion, and, if necessary, through mediation and arbitration, according to the Rules of Procedure of the Institute for Christian Conciliation (http://www.iccpeace.com/Rules/index.html). If an issue does arise, both counselor and counselee will bring the issue to the church leadership at Harbins. Counselors will exercise discretion in continuing counseling with non-member counselees in situations of potential counseling, while Christian counselees agree to submit to the authority of their local church to pursue reconciliation. Counselors and counselees agree not to take this matter to any secular court system (1 Cor 6:1-7).
FOR NON-MEMBERS. We are more than happy to provide biblical counseling for you. We will strive to provide the best biblical care we can for free. We do not charge for counseling, but many of our counselors are volunteering their free time to care for you and occasionally we will provide helpful resources for you at our own expense. If you are the member of another church and you appreciate the care you have received, feel free to make a donation to either Harbins Community Baptist Church or the biblical counseling ministry. Any donations will help us continue to provide biblical care to others in our community.
By signing your name below, you are agreeing to have read the information within this document and receiving the type of counseling care described above and will abide by the terms, stipulations, and expectations stated therein, therefore releasing from liability the Church and any/all participating churches, pastors, agents or employees, from a claim or litigation whatsoever arising from the undersigned’s participation in the above-mentioned biblical discipleship counseling ministry.
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