About Counseling Specialties Couples & Marriage Anxiety, Depression, & Stress Addiction Abuse & PTSD Eating Disorders Leader Care And More Intensive Counseling Retreat Fees & FAQ’S Blog Contact Us Counseling Application for Minors "*" indicates required fields WE WANT TO GET TO KNOW YOU A LITTLE BIT... Please fill out this form as best you can. Be honest and specific. It should take you no more than 30 minutes. We look forward to meeting you!Basic InformationDate* MM slash DD slash YYYY Name* First Last Age*Gender* Male Female Prefer Not To Answer Email* Phone*Do you have any food allergies or restrictions? Please answer yes or no; if yes, please let us know what your allergies/restrictions are.*Tell us about your school.* I'm homeschooled. I attend private school. I attend public school. What grade are you in?*Reasons for CounselingWhy are you filling out this form?* My parents think I need help through counseling. I think some counseling may be helpful for me. Why are do you think you are coming to Twelve Stones? What problems are you dealing with? Describe it as best you can.*Do you have any fears or concerns about coming to counseling?*Do you have any health problems that would make it difficult for you to sit in counseling?* Yes No Have you ever been to counseling before?* Yes No If you said yes to the previous question, what did you learn from that counseling experience?*Tell Us About Your FamilyAre you growing up in a "typical family" with mom and dad?* Yes Yes, but I am adopted. No, I only have one parent. No, we have a blended family (step parent and/or step siblings) Dad's Name* First Last Dad's Phone Number (Please insert N/A if this question doesn't apply)*Dad's Email (Please insert N/A if this question doesn't apply)*Mom's Name* First Last Mom's Phone Number (Please insert N/A if this question doesn't apply)*Mom's Email (Please insert N/A if this question doesn't apply)*What has it been like to grow up in your family?Healthy rules - We have rules but I can give input and I don't feel burdened by them.* Yes No Affectionate - My parents often tell my they love me and show me affection.* Yes No Religious - Church and faith are important in my family.* Yes No Only rules - We have a lot of rules. I feel like I'm not heard or understood.* Yes No Perfection - I feel a lot of pressure and often don't feel like I'm good enough.* Yes No Substance Abuse - Someone in our home has struggled with alcohol and/or drugs.* Yes No Critical - Little or no encouragement; I'm often told that I mess things up.* Yes No Details About Your LifeIn 1-2 sentences, how would you describe your life so far?*Which people have been most influential in your life?*For example: - Dad: Teaches me a lot of things - Mom: Unconditional love -Coach: Believes in meWhat have been your happiest experiences so far in your life?*What have been the most difficult experiences in your life so far?*If you could change ANYTHING about your life, what would you change? Why is that important for you?*Tell us about going to church? Do you like it? Do you hate it? Why?*Talk about your faith. Do you believe in God? When did you start believing? Did you have help learning about God?*Do you know for sure that you will go to heaven? What are the reasons you chose this answer?*Do you have friends? Few? Lots? Tell us a little bit about them.*Personality InformationWhich 3 words would you use to describe yourself?* Angry Shy Fearful/Anxious Lonely Self-Critical Depressed Moody Serious Content Outgoing Courageous Life of the party Self-confident Happy Stable Easy going What other words describe you well?* Assertive Optimistic Rejected Impatient Impulsive Sensitive Passive Pessimistic Accepted Patient Measured Thick-skinned Other If "Other" was selected, please describe:What, if anything, makes you really happy?*What, if anything, makes you really sad?*What, if anything, makes you really angry?*What, if anything, makes you feel afraid or anxious?*Do you have recurring thoughts about yourself? What are they?*For Example: "I have never been good enough." "I am not smart." "Nobody loves me."Additional InformationAre you taking any prescription medications?* Yes No Have you ever used drugs for non-medical purposes?* Yes No Have you ever been arrested?* Yes No Do you have problems sleeping?* Yes No Do you have problems eating (too much or too little)?* Yes No Have you recently had any significant life events (moving, a breakup, being bullied, someone you loved died, etc.)?*What have been your biggest disappointments?*When you feel unsafe or uncomfortable, how do you deal with that?*Has anyone ever hurt you or made you feel uncomfortable physically, emotionally or sexually?*Would you say that anyone ever has wounded, hurt, or abused?*Is there any other information your counselor should know?*Advocate InformationAll the people who come to us need to bring an advocate with them. This is someone who knows you pretty well and who you trust. They should be Christ-followers and should have time to invest in you as a mentor. YOUR PARENTS MAY HAVE TO HELP YOU CHOOSE SOMEONE.Advocate's Name* First Last Advocate's Phone*Advocate's Email* IMPORTANT INFORMATION - READ CAREFULLY* I agree to the privacy policy.OUR GOAL Our goal in providing Christ-centered 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 that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than on those of secular psychology or psychiatry. Although some of the pastoral or lay counselors of Twelve Stones may be licensed in other fields, such as medicine or psychology, they will not practice in that capacity but as biblical counselors under the authority of the board of directors that serve Twelve Stones Ministries. NOT PROFESSIONAL ADVICE If you have significant legal, financial, medical or other technical questions, you should seek advice from independent professionals in those fields. Our ministry staff and lay counselors will be happy to cooperate with such advisers and help you to consider their counsel in the light of relevant scriptural principles. CONFIDENTIALITY We believe confidentiality is an important aspect of the counseling process. Therefore, we will carefully guard the information you entrust to us. There are four situations, however, when it may be necessary for us to share certain information with others: 1. In discussions with the pastor of your local church, physician, previous counselor and/or your advocate for the sole purpose of gaining information for your care or to help in follow up and after care. 2. When a counselor is uncertain of how to address a particular problem and needs to seek advice and wisdom from another Twelve Stones staff member. We will make every effort to be sensitive to your situation. 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 Proverbs 15:22; 24:11, Matthew 18:15-20). COMMUNICATION AND COMMUNITY It is the mission and vision of Twelve Stones to help local church more faithfully care for those in their flock who are hurting. It is imperative to our mission and your long-term care that we stay in consistent and regular communication with the pastoral leadership of your local church and/or the person you have designated/chosen as your advocate. This form gives us permission to discuss the necessary information with the appropriate church staff and concerned parties in regards to your situation in accordance with the below confidentiality guidelines. Please be assured that our counselors strongly prefer not to disclose personal information to others, and we will help you find ways to resolve a problem as privately as possible. RESOLUTION OF CONFLICTS On very rare occasions, a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts are resolved in a biblical manner, we require all of our counselees to agree that any dispute that arises with a counselor or with Twelve Stones staff as a result of counseling will be settled by mediation from a third party; our board of directors, and/or leadership from your church. We will make every effort to resolve conflict in a manner according to the principles of scripture and under the authority of the local church. HAVING CLARIFIED THE PRINCIPLES AND POLICIES OF OUR COUNSELING MINISTRY, WE WELCOME THE OPPORTUNITY TO MINISTER TO YOU IN THE NAME OF CHRIST. WE DESIRE TO BE USED BY GOD AS HE HELPS YOU TO GROW IN SPIRITUAL MATURITY AND PREPARES YOU FOR USEFULNESS IN HIS BODY. IF THESE GUIDELINES ARE ACCEPTABLE TO YOU, PLEASE SIGN BELOW.Electronic Signature*Type Your Name to Sign!Once you click "SUBMIT" you will have completed the application. We will work with your parents to get all other details for counseling arranged. Thank you for taking the time to help us learn more about you! Sincerely, Your Twelve Stones TeamEmailThis field is for validation purposes and should be left unchanged. Δ Have A General Question? Contact Us Free Download Three Signs an Intensive Counseling Retreat is Right for You Name(Required) First Last Email(Required) EmailThis field is for validation purposes and should be left unchanged. Δ
