Personal Background Form - The Center for Biblical Living

Thank you for contacting The Center for Biblical Living.

The following form should only take you 10-15 minutes. Please be thorough in completing each section. This information will help us be more informed for our initial appointment.

Name*
First Last
Email*
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Before your first appointment, I would like you to know more about me and about our mutual responsibilities.
Before meeting together, we would like you to know more about this ministry and about our mutual responsibilities.
The Center for Biblical Living
Student Care at The Southern Baptist Theological Seminary (SBTS) is staffed by The Center for Biblical Living (CBL). CBL does not employ professional psychologist; we have no license in the Commonwealth of Kentucky to practice Psychology. However, many but not all of our staff have at least a Master of Arts in Biblical Counseling. This is a theological degree, and not a medical degree. Even though we hold degrees from The Southern Baptist Theological Seminary, that institution bears no liability regarding our counsel to you. The advice we give is our own.
Accountability
Your meeting with CBL staff is a service to The Southern Baptist Seminary and as a courtesy we comply with the student code of conduct instituted by the leadership of SBTS. CBL reserves the right to make them aware of any situation we are involved with. You are encouraged to contact SBTS if you have questions or concerns about the service CBL provides. At the most basic level, CBL staff are Christians giving advice for living based on their understanding of Scripture, in conjunction with historic Christianity. If you have any reservations about this, we would be happy to discuss them with you. You are of course free to decide if you would rather not meet with CBL staff under these circumstances.
In situations involving CBL male staff meeting with a woman, we require a third-party presence. If the woman is married, this will preferably be her husband. Another trustworthy woman is also ideal. Additionally, CBL male staff reserve the right to discuss issues with their wife, who will observe the same guidelines of confidentiality the husband does, and perhaps bring her into the situation if deem it in the best interest of the situation. CBL female staff will not meet with a male alone for any circumstances.
The Nature of Counseling with CBL
We believe the Gospel of Jesus Christ is what will ultimately change how a person responds to the difficulties of their situation. You should expect meetings to be shaped by a God-centered view of human life as found in the Christian Scriptures. This biblical view will take seriously the physical, social, and developmental aspects of your difficulties while calling you to make changes in your thinking and behavior. CBL staff believe that people’s souls are built up as they grow in their relationship with God. This process doesn’t happen apart from our personal effort to seek Him. Expect that we will recommend that you engage in some spiritual practices to enhance your relationship with God. You will be asked questions about your past, present, family, church, social relationships, and spirituality to get to know you better. You do not have to answer any questions and can discontinue whenever you wish. Meetings will typically last about an hour to an hour and a half in length. If necessary, depending on the need, CBL staff may refer you to a Medical Doctor and/or Medical Counselor.
Confidentiality
It is assumed that everything that is said to CBL staff will generally remain confidential, with the following caveats: Circumstances under which we might need to communicate to others regarding our meetings include (but are not limited to):
1) A person indicates an intention to harm him or herself or someone else;
2) A person has recently committed sexual or physical abuse; especially regarding minors. We are mandatory reporters.
3) A person has engaging in repeated, ongoing serious immorality (e.g. adultery) that might require the involvement of SBTS as well as one’s church;
4) The person is a minor and there is belief it is in the best interest of the child to disclose information to the parent;
5) CBL staff need the counsel of your pastor/elder as to how best to direct you biblically; or
6) A court of law requires the release of information given in our meetings. You will be free to sign a release-of-information form designating someone you permit CBL staff to speak with about your situation.
Your Rights
You have the right to discuss possible outcomes and challenges regarding meetings and receive an estimate of the predicted length, goals, and outcome, as well as alternative options. You have the right to ask about and/or refuse biblical counseling methods used. You are encouraged to report to the appropriate authorities if you have any grievances regarding CBL staff actions. You may conclude meeting at any time.
Confirmation
I understand the following: 1. CBL does not employ licensed psychologists or psychiatrists. I agree not to expect or rely on the application of any rules or regulations issued by the Commonwealth of Kentucky for professional counselors or interns.
2. CBL works from a Christian framework as described above.
3. All meetings are confidential with the exceptions noted above. I agree not to expect strict confidentiality, but to expect that CBL staff will exercise discretion based on what they believe is in my best interest in determining whether to communicate what we discuss to others.
4. I am free to end our meetings at any time.
5. CBL is free to end our meetings at any time.
6. Before concluding permanently, I may be referred to another for biblical direction and counsel.
7. If I have any concerns about our meetings, I am free to contact The Center for Biblical Living and/or The Southern Baptist Theological Seminary.
8. Out of courtesy, I will give at least 24 hours prior notice before canceling an appointment.
I understand and I am in agreement with the information presented on the Informed Consent Form above.*

Basic Information
If someone referred you to Student Care, please share with us their name?*
Which phone number should we use?*
What is your address?*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is your birth date?*
MM slash DD slash YYYY
Where was home while growing up?*
Are you female or male*

Men Only
Please explain any sense of pressure or responsibility that affects your functioning, such as tension or tendency to be angry.*
What is your status?*

Women Only
Please explain any sense of pressure or responsibility that affects your functioning, such as tension or tendency to cry or anger.*
Please explain any menstrual symptoms that affect your functioning, such as tension or tendency to be emotional.*
What is your status?*

Marriage
What's your spouse's first name?*
Which phone number should we use for your spouse?*
Which email address shall we use for your spouse?*
Where was home for your spouse growing up?*
What is your spouse's birth date?*
What is your wedding date?*
Give a brief statement around the circumstances of how you met.*
How long of a period were the two of you in a relationship before your wedding?*
Is your spouse willing to join you?*
Is your souse supportive of you coming in?*
Do you feel safe/secure at home?*
Are or have you ever been separated from your spouse?*
Have either of you been previously married?*
Have either of you ever filed for divorce?*
What would you rate your marriage relationship as a whole (1 to 5)?*
- 1
- 2
- 3
- 4
- 5
Use this space to provide additional information you believe is helpful for us to know.
Do you have children?*

Children Info
Please list out your children's name, age, and gender:

Growing Up Years
Describe your relationship to your father.*
Describe your relationship to your mother.*
Describe your relationships with siblings (include number and birth order).*
Describe any significant events in your family life growing up.*
If you lived with anyone other than your parents, please describe the nature of that relationship.*
Use this space to provide additional information you believe is helpful for us to know.

Health Information
Describe your health generally.
Describe any chronic conditions, significant illness, injury or handicaps.
Describe any interpersonal problems you may have had at (home, school, work, etc…).
Please explain if you have ever had a severe emotional upset.
Have you ever been arrested?*
- No
- Yes
Use this space to provide additional information you believe is helpful for us to know.

Substance Use
Do you drink coffee?*
Do you drink other caffeinated drinks?*
How often and how much caffeine?*
Do you smoke?*
Have you ever used drugs for anything other than medical purposes?*
- No
- Yes
Use this space to provide additional information you believe is helpful for us to know.

Professional Medical Information
Physician’s name and address
Date of last medical exam:
List current Medical medications and dosages.
Have you ever received Psychiatrist or Psychologist care?*
Use this space to provide additional information you believe is helpful for us to know.

Spiritual Pursuit
What is the name of the church you currently attend?*
What is the name of the pastor?*
Are you a member?*
- No
- Yes
How often do you attend church per month?*
Explain your church involvement.*
What denominations or religions have you been involved with in the past?*
Please explain any significant changes in your religious life?*
Which statement best describes your relationship to Jesus Christ?
Describe your prayer life.*
How often do you read the Bible?
Use this space to provide additional information you believe is helpful for us to know.

Background form

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Basic Information

Men Only

Women Only

Marriage

Children Info

Growing Up Years

Health Information

Substance Use

Professional Medical Information

Spiritual Pursuit

Concern Check List

Concern Overview in Your Own Words