CONSENT TO INDIVIDUAL
COUNSELING FORM
We welcome you to the Biblical Care Counseling ministry of the Rock Church. Our
goal at the Rock Church in providing Christian Biblical counseling is to help you meet
the challenges of life in a way that will please and honor the Lord Jesus Christ and
enable you to enjoy fully His love for you and His plans for your life.
Biblical Basis:
The Rock Church believes that the Bible provides thorough guidance and instruction
for faith and life. We believe the Bible is God’s all-sufficient guide for relational living.
There is a route to life. Our Lord is that way. Christ is the truth who frees us to love.
He is the life who satisfies the deepest thirsts of our soul. Therefore, our short-term
guidance is based on Scriptural principles that are supported by practical guidance.
Care Counselors at the Rock Church are not licensed as therapists or mental health
professionals but are trained leaders who can provide solid Biblical guidance.
Not Professional Advice:
As a discipleship ministry of Rock Church, our services are free. Our Care
Counselors are not authorized to provide professional advice or services. We offer to
you the following:
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Individual Biblical counseling regarding spiritual and personal issues.
Marital Biblical counseling.
Family/parental Biblical counseling
If you have significant legal, financial, medical, or other technical questions, you
should seek assistance from an independent professional. The Care Counseling
Ministry will make available a list of professional counselors upon request.
Confidentiality:
Confidentiality is an important aspect of the counseling process, and we will
carefully guard the information you entrust to us. Please be assured that our
counselors strongly prefer not to disclose personal information to others, and
they will make every effort to help you find ways to resolve a problem as privately
as possible. However, it is important for you to understand that there are certain
circumstances where it may be necessary for us to share information with others:
1) When a Care Counselor needs to seek guidance from the Care Counseling
Pastor.
2) Where California law dictates:
 If the Care Counselor has reasonable cause to believe that a child or
elder has been the victim of abuse, he/she must report the suspected
abuse to the appropriate protective agency immediately by telephone,
to be followed by a written report within 36 hours.
o “Child abuse” includes:
1. Physical abuse/injury (P.C. 11165.4)
2. Sexual abuse and/or exploitation (P.C. 11165.1)
3. Emotional abuse or willful cruelty (P.C. 11165.3)
4. Neglect (P.C. 11165.2)
o “Elder abuse” includes (P.C. 368):
1. Physical or sexual abuse
2. Neglect
3. Financial abuse
4. Psychological abuse
5. Self-neglect
 If the counselor has reasonable cause to believe that you could
possibly be dangerous to yourself or to the person or property of
another, he/she will report this concern to the appropriate authorities
or individuals.
3.) Notes are kept about your counseling session. The information is limited to
dates, times, and any pertinent information regarding major areas of concern
or safety. The notes are electronically stored in a secure database with
access only given to the counselor and the Care and Concern Ministry.
Resolution of Conflicts:
On rare occasions a conflict may develop between a Care Counselor and a
counselee. In order to make sure that any such conflicts will be resolved in a
Biblically faithful manner, we require all of our counselees to agree that any dispute
that arises with a Care Counselor or with the Rock Church as a result of counseling
will be settled by mediation and, if necessary, legally binding arbitration in
accordance with the Rules of Procedure of the Institute for Christian Conciliation.
Our Human Resources Department is happy to provide you with additional
information on our dispute resolution policies and will provide you with a copy of the
Rules of Procedure at your request.
Agreement:
By signing this consent, you acknowledge and agree:
1) That you have read this Consent Form and agree to abide by the principals
and policies of the Rock Church Care Counseling Ministry as outlined above.
2) That you have had the opportunity to ask questions and gain clarification from
a Rock Care Counselor staff member regarding this Consent Form.
3) That you are seeking, and the Rock Church is providing care counseling.
The Rock Church has informed you that it does not and will not provide any
form of professional mental health counseling.
4) That you will not attempt to subpoena or require any Rock Church counselor
to appear in any legal proceeding related to any matters discussed during
counseling; nor will you attempt to subpoena any notes or records related to
this counseling.
Having clarified the principles and policies of our counseling ministry, we welcome
the opportunity to minister to you in the name of Jesus Christ. We desire to be used
by Him as He helps you to grow, mature and transform into the individual He wants
you to become. If the principles and policies outlined above are acceptable to you,
please sign below.
Signed _____________________________________
Date _______________
Print Your Name: ____________________________
Once completed, please turn in to
The Rock Church
2277 Rosecrans Street
SAN DIEGO, CA 92106
619.226.7625 PH
619.223.3863 FAX
INDIVIDUAL COUNSELING INTAKE FORM
This form is for individual only. If you are seeking marital counseling, please request a Marriage
Profile Form. Please fill out the following information for an appointment with our Care Counselors.
Name: ______________________________________ Phone:(___)____________ Date:__________
First
Last
Address:__________________________________________ E-Mail: __________________________
Gender: M F
Birthdate:__________
Marital Status (circle one):
Single
Age: _____ Occupation:_________________________
Dating
Married
Separated
Divorced
Widowed
Referred by: _________________________________
What Rock campus do you attend? _____North County _____East County
_____Point Loma ______San Ysidro
MARRIAGE AND FAMILY INFORMATION (If you are unmarried and have no children skip to next section)
Name of Spouse: ______________________________
Spouses Age: ______
Religion: ____________________ Length Married: _____________________
Give brief information about any previous marriages: ___________
__________________________________________________________________________________
Do you have any children?
Y
N
(If yes, please give names and ages)
___________________________________
Name
Age
_________________________________________
Name
Age
___________________________________________
Name
Age
__________________________________________________
Name
Age
ROCK CHURCH INFORMATION
Do you regularly attend the Rock Church?
Y
N Attendance per month (#): ___________________
Which service do you normally attend? 8AM
Do you attend a Rock LIFE Group?
LIFE Group Facilitator’s Name:
10AM
Y
N
Noon
5PM
7PM
If yes, how long? _______________
_______________________________________________
Have you consulted with them regarding your specific concern/need?
Y
N
Have you received Jesus Christ as your personal Savior? (Briefly explain): __________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PERSONAL INFORMATION
1. What is the challenge that has motivated you to request care counseling?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2. Have you received counseling for this particular issue before?
If so, who counseled you, when, and what was the outcome?
Y
N
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3. How are you dealing with this current challenge? ________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
4. What are you expecting to receive from Rock Church Care Counseling? _____________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Are there any other issues that you think we should know?
6. Please list all your available times for counseling ________________________________________
7. Our counselors take time out of their schedules for the appointments please make every effort to
make your scheduled appointments. What would be the best way to reach you?
Text

Phone Call
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
Email
Signed ___________________________________________________________
Date: _____________
For Office Use Only
Counselor Name:_______________________________ Care Counselor
Reviewed By: ____________________________________
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PST
Other
Date __________________