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Problem Description

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Information About Children:


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What: Frequency:

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* Permission to contact your pastor includes sharing information on this PDI.

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Women Only

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Problem Checklist

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Counseling Agreement

Before filling out the Personal Data Inventory information, it is important that you read and understand the following information regarding biblical counseling with me.

I am not certified by the State of California, but I am certified with the Association of Certified Biblical Counselors (a Biblically sound organization).

There are, however, several conditions upon which counseling cases will be initiated, and possibly terminated. They are as follows:

  1. Counseling of members of my local church always takes precedent over all outside counseling.
  2. Since I am closely tied with two counseling training institutions, I may seek your permission to have a trainee in the counseling room with us for observation. I will respect your decision if you decline, but it is valuable experience for the trainee and a way you can serve the body of Christ.
  3. All counseling will be conducted in accordance with my understanding of the Scriptures. Your counseling will be biblical in that the Scriptures are the final authority in all cases. If you are not sure that you will be interested in biblically-based counseling, you have the option of attending one or two sessions to discover what biblical counseling is like. If you are unwilling to use the Bible as the final authority in counseling or unwilling to do the homework assigned, sessions will be terminated.
  4. Please encourage your pastor from your local church or one of those in its leadership to accompany you in counseling sessions. I fully recognize and respect the authority and the discipline of your church. And, in addition, this makes transfer back to the pastoral care of your church much easier to effect. If you are not attending a church, I will expect you to attend a Bible preaching and believing church weekly. If you so desire, I will be glad to make a recommendation.
  5. Information disclosed in counseling sessions will be held confidential only as I believe the Bible or the State requires. Absolute confidentiality is not scriptural. In certain circumstances the Bible requires that facts be disclosed to selected 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.
  6. At any time during the counseling, for reasons sufficient to myself—as also you—shall have the option of terminating counseling.
  7. All counseling is done free of charge as a ministry to you. However, part of the weekly homework assignments may require purchasing materials that correspond to the counseling.
  8. It should be understood that biblical counseling consists of the giving of scriptural advice and the practical application of the same to each individual. Yet, you are held fully responsible for how you implement that advice.

I am confident that the Bible has all of the information necessary for life and godliness (2 Pet. 1:3). There are no problems between persons that the Bible fails to address either in general or specific principles. I am not infallible, nor do I pretend to know all there is to know about biblical teaching and its applications to life, but I am well equipped and competent to help you change. I will make a point to differentiate between God's commands and my suggestions. I will also honestly tell you if I am stymied and will seek help.

If a conflict should arise between you and me, we must agree to resolve the dispute outside the secular court system. Conciliation will be sought under submission to and direction of certified Christian Conciliator.

Electronic Signature

I, , 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:   


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Thank you for taking the time to fill out this form! Your complete and honest answers will aid the counseling process and allow me to better understand you and your situation.

I would encourage you, if you have not already, to go back and review your answers. Once you click "Finish" I will receive an email with your answers. If you filled in your email address under the Personal section, you will receive a copy of your PDI.

I will contact you in the next few days to set up a meeting time and location that is convenient for both of us. If you have any questions or concerns, please do not hesitate to contact me by email or (661) 714-2574.

Click "Finish" to submit your Personal Data Inventory.