Biblical Counseling Request

We believe the Bible, centered on the gospel, is sufficient, authoritative, and powerful through the Holy Spirit to address every human behavior, thought, and desire and bring it into conformity to Christ. Biblical counseling is intense, temporary discipleship aimed at addressing specific behaviors, thoughts, and/or desires through the Word of God. Most biblical counseling requires 1 to 8 sessions.

Counseling addresses your behaviors, thoughts, and desires. That may include things like clarification about a biblical position/action/response, addressing a sinful pattern in your life, or coping under difficult circumstances. Counseling is not for receiving advice to "fix" someone else.

Name (Required)

Email Address (Required)

Please Note:

Counseling sessions will be granted according to the availability of the pastors/counselors. Priority is given to MBC members. To request counseling, please complete the following form, then click Submit. The form could take 30 minutes or more to complete and it cannot be saved while partially completed. Please allow enough time to finish in one sitting.

General Information:

Please complete all of the following fields.

What is your phone number? (Required)

What is your current address? (Required)

How long have you lived at your current address? (Required)

What is your date of birth? (Required)

What is the highest education level you have completed? (Required)

Select one:

Your Counseling Request:

Describe the reason you are seeking counseling in a few words. (Required)

100 characters or less. You will be able to provide more detail in the next response.

Give additional details or circumstances related to the reason you are seeking counseling. (Required)

500 characters or less

Are you receiving any other counseling or treatment for this issue? (Required)

Check all that apply:

Yes, from a professional counselor

Yes, from a professional psychologist

Yes, from a professional psychiatrist

Yes, from another pastor

Yes, from a church member

Yes, from Christian family/friends

Yes, from non-Christian family/friends

Your Availability:

Check all available times that apply. (Required)

Check all that apply:

Tue-Fri 8am - 12pm

Tue-Fri 1pm - 5pm

Tue - Fr After 5pm

Saturdays any time.

Sunday afternoons.

Your Relationships:

Please complete all of the following fields.

What is your marital status? (Required)

DO you currently live with anyone? (Required)

How would you describe the overall condition of relationships in your home? (Required)

List any positive/happy relationships with people inside your home. (Required)

Example: roommate, son, spouse, etc.

List any negative/tense relationships with people inside of your home. (Required)

Example: roommate, son, spouse, etc.

How would you describe your overall relationship with your parents? (Required)

How would you describe your overall relationship with your in-laws?

List any close positive relationships with relatives outside of your home.

Example: mother, brother, in-laws, etc.

List any close negative/tense relationships with relatives outside of your home.

Example: mother, brother, in-laws, etc.

Do you have a close friend or group of friends?

Do you have close relationships with anyone in a local church? (Required)

Your Employment:

Please complete all of the following fields.

What is your employment status?

Check all that apply.

Full-time student

Part-time student

Working full-time

Working part-time

Homemaker

Unemployed - searching

Unemployed - not searching

Unemployed - disabled

Retired

How many hours do you generally work per week? For students, how many credit hours? (Required)

Describe any recent changes in your work/school situation.

Consider all changes, even seemingly small ones.

Your Sense of Wellbeing:

Complete all of the following fields.

How would you describe your general sense of wellbeing? (Required)

Check all that apply. Could be a combination - e.g. usually content AND sometimes happy. In that case you would check both answers.

I usually feel positive/happy

I often feel positive/happy

I sometimes feel positive/happy

I usually feel content/steady

I sometimes feel content/steady

I often feel content/steady

I sometimes feel mildly depressed

I often feel mildly depressed

I usually feel mildly depressed

I sometimes feel deeply depressed

I often feel deeply depressed

I usually feel deeply depressed

I swing between extremes - extremely positive to deeply depressed

I have recently thought about hurting myself

Check the 3-5 words below which describe what concerns you most.

Shame / Embarrassed

Resentment

Fear

Anxiety

Grief (loss)

Anger

Despair

Depressed

Hopeless

How would you rate your overall busyness? (Required)

Do you have hobbies that you enjoy? (Required)

List hobbies or enter 'None'

How would you rate your overall stress or anxiety level? (Required)

Low

High

What do you perceive as your greatest source of stress or anxiety? (Required)

Select one.

Your Medical Information:

All medical information is relevant and confidential. Please complete all of the following fields.

List any medical conditions which affect your day to day comfort or abilities:

Are you currently being treated by a physician? (Required)

Are you taking any medications you feel it is important to share?

Do you have a regular exercise routine? (Required)

How much sleep do you generally get each night? (Required)

How would you rate your quality of sleep? (Required)

Describe any recent change in your sleep habits.

Describe any recent changes in your diet or eating habits.

How would you rate your physical health? (Required)

Describe any recent changes in your overall physical health.

Your Alcohol, Smoking, and Substance Use:

Please complete all of the following fields.

How often do you usually drink alcohol? (Required)

Do you use any illegal substances or any prescriptions for anything other than the prescribed use? (Required)

Your Personal Faith:

Please complete all of the following fields.

Would you say you are a Christian? (Required)

Are you a member of a local church? (Required)

How often do you usually attend church? (Required)

Please list any ministry involvement:

100 characters or less

Have you been discipled by someone in the church? (Required)

Do you attend a small group for Bible Study, prayer, and discipleship? (Required)

How often do you meet with people from church outside of worship services? (Required)

How would you rate your spiritual health? (Required)

Describe any recent changes in your spiritual habits.

Is there any other information that would be helpful for a counselor to know?

Your Commitments:

Will you commit to coming to all of your scheduled counseling sessions except in the event of an emergency? (Required)

Will you commit to completing all of the assignments and readings assigned to you by the pastor/counselor to the best of your ability? (Required)

Terms and Conditions:

Do you understand that we offer biblical counsel 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 His love for you and His plans for your life? (Required)

Do you acknowledge and consent that you are not seeking counseling from a licensed clinical counselor, psychologist, psychiatrist, or mental health professional? (Required)

Do you understand and consent that, though some of our counselors may be lawyers, doctors, or other professionals, our counselors are not providing advice in those areas or capacities during the counseling process? (Required)

Do you acknowledge that Milwood Baptist Church believes the Bible provides sufficient guidance and instruction in all matters of faith and life, and, therefore, our counseling is based on biblical principles. (Required)

Do you consent to receive counseling according to the beliefs and practices of Milwood Baptist Church? (Required)

By typing your name below and submitting this form you represent that all of your answers are truthful and you agree to the commitments, terms, and conditions stated in this form. (Required)

Type your name.

Our Sundays

9:30 AM | Building Blocks

10:30 AM | Worship Service

5:00 PM | Prayer Service

OUR JOY. HIS GLORY.

512.834.1100

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