Counseling Training the saints to certification in biblical counseling Training Training Info Training Registration Online Training Supervision Counseling Counseling Info Counseling Sign up Counseling FAQ’s Partner with Us Donate Ways to Support Events Event Info 25th Anniversary Celebration Golf Outing Blog About Us Who We Are Beliefs Staff and Board Contact Us Counseling Sign Up Form Step 1 of 5 0% POLICIES & PROCEDURES AND CONSENT TO COUNSEL Rod and Staff Ministries (RSM) is committed to the inerrancy, authority, and sufficiency of Scripture. We believe that the Bible contains all that is necessary for life and faith. Therefore, our counseling is based on biblical principles rather than those of secular psychology or psychiatry. Our desire is to help people solve life’s problems biblically, in a manner pleasing God. Given the above commitments, belief, practice, and desire we make the following affirmation and denial: WE AFFIRM that God created mankind male and female and that this divinely determined distinction is good, proper, and to be celebrated. Maleness and femaleness are biologically determined at conception and are not subject to change. The curse of sin results in sinful, disordered affections that manifest in some people as same-sex attraction. Salvation grants sanctifying power to renounce such dishonorable affections as sinful and to mortify them by the Spirit. We further affirm that God’s design for marriage is that one woman and one man live in a one-flesh, covenantal, sexual relationship until separated by death. Those who lack the desire or opportunity for marriage are called to serve God in singleness and chastity. This is as noble a calling as marriage. WE DENY that human sexuality is a socially constructed concept. We also deny that one’s sex can be fluid. We reject “gay Christian” as a legitimate biblical category. We further deny that any kind of partnership or union can properly be called marriage other than one man and one woman in a lifelong covenant together. We further deny that people should be identified as “sexual minorities”—which serves as a cultural classification rather than one that honors the image- bearing the character of human sexuality as created by God. SCRIPTURE: Genesis 1:26-27, 2:24, 4:1, 19:24-28; Matthew 19:3-6; Romans 8:13; 1 Corinthians 6:9-11; 1 Timothy 1:10; Jude 7 • I am committed to seeking new insights into a personal, lovingly obedient relationship with Jesus Christ, which may involve new understandings from God’s Word, and to pursuing a transformed life that reflects God’s grace as revealed in His Word. • I will fulfill the weekly assignments or my sessions may be terminated. • I will consistently attend a Bible-believing church each Sunday while I am in counseling. • I will keep the appointment time or will call to cancel 24 hours in advance. • I understand that Rod and Staff Ministries is a Biblical Counseling and Training Center, and therefore agree to have a trainee(s) and/or an audio taping for training purposes in the counseling sessions with me. • If I have a dispute with your counselor, the procedure for addressing the concern(s) are as follows: First, speaking truth in love, go to the counselor, as Scripture requires. If reconciliation cannot be accomplished, contact the director in writing, explaining my concern. He, in turn, will contact you regarding your dispute at his earliest convenience. Finally, if necessary, the director would be pleased to meet with your pastor provided the above is pursued. • I agree to hold any counselor with Rod and Staff harmless from any advice, counsel or suggestions rendered during our counseling sessions. I recognize that his/her role is to assist me in hearing and understanding God’s will in the matters we discuss. We will not, therefore, sue or engage in any type of litigation negatively affecting them or the organization.I affirm the accuracy of the personal information contained in the following pages, and have read the above information and agree to the conditions set forth therein. I hereby agree to the following conditions:* Requested Counseling Type Individual (Male) Individual (Female) Individual (Youth) Couples While we typically have a waiting list to see available counselors, it helps if we know your general availability to pair you with a counselor. Please select any available times below. (Times are general. When a counselor becomes available, we will be in touch to set exact appointment times.)* Monday Mornings (8-11 am) Monday Afternoons (Noon-4 pm) Monday Evenings (5-8 pm) Tuesday Mornings (8-11 am) Tuesday Afternoons (Noon-4 pm) Tuesday Evenings (5-8 pm) Wednesday Mornings (8-11 am) Wednesday Afternoons (Noon-4 pm) Wednesday Evenings (5-8 pm) Thursday Mornings (8-11 am) Thursday Afternoons (Noon-4 pm) Thursday Evenings (5-8 pm) Friday Mornings (8-11 am) Friday Afternoons (Noon-4 pm) Friday Evenings (5-8 pm) Weekends (Please specify below.) Other (Please specify below.) Please tell us times when you are available: Section BreakName* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneText NotificationsWould you like to receive text notifications for appointments via text? Yes No Cell Phone CarrierPlease provide the name of your cell phone provider (i.e. Sprint, AT&T, Verizon, etc.) Gender* Male Female Birthdate* Month Day Year Email*Required for scheduling appointments. Marital Status* Single Engaged Married Separated Divorced Widowed Military ServiceIf you served in the military, please let us know what branch. Occupation* Education*Highest level of education achieved High School College Grad School Post Graduate Referred ByIf you were referred by a friend, church or other organization, please let us know. Save and Continue Later Background InformationPlease answer each of the following questions. You will have an opportunity to provide more detailed information during your first session with your counselor.Please briefly describe the problem.*What have you done about it?*What are your expectations in coming here?*As you see yourself, what kind of person are you? Please describe yourself.* Save and Continue Later Information About Spiritual LifeDo you currently attend church?* Yes No Spiritual Life SurveyThe following group of questions are related to your spiritual heritage and current faith experiences and beliefs.Denominational Preference* Church Name* Church Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pastor's Name* First Last Have you contacted your pastor about counseling?*We recommend always starting counseling by discussing with your local pastor. Yes No Church Notification*Please note - we will be informing your Pastor via a letter that you are coming for counseling at Rod & Staff Ministries. Please check the below box and initial indicating that you were informed that we will be contacting your pastor. I acknowledge that I have been informed. Initial* Frequency of Attendance*(times per month) Spouse's Church Attendance (if applicable)(times per month) Are you a member?* Yes No How long have you been a member of your church?* What are you learning through the sermons, bible studies, messages at your church?*Ministry Involvement*Please list any ministries you are actively involved in at your church.Have you been baptized?* Yes No Baptized? If so, when. How often do you pray?* If you pray, what do you pray about?*If God asked you, "Why should I allow you into my Heaven?", how would you respond?*Have you received Christ personally as your Savior?* Yes No Uncertain Don't Understand When did you receive Christ as your personal Savior? How do you know that Jesus Christ is your Savior?*What changes took place in your life when you became a believer?*How many times did you read your Bible last week?* How many times did you read your Bible the week before?* Describe your personal devotions* Save and Continue Later Prior CounselingThis section will ask about details of any previous counseling you may have participated in previous to starting with Rod & Staff Ministries.Have you had counseling before?* Yes No Previous Counseling Experiences ListTo add an additional instance of counseling, just click on the small "+" circle to the right of the last field.Counselor's NameDates (From - To)Medications PrescribedOutcome/Diagnosis Do we have your consent to contact your counselor(s)?By selecting yes, you are confirming that we have your permission to contact your counselor. Yes No Personal Habits and HealthPlease let us know a little bit about your personal habits, activities and health lifestyle.How many hours of sleep do you get each night?* When do you...*In each box please format the answer like: 10pm, 11pm, 7am, 7:30amGo to BedFall AsleepWake-upGet Out of BedDescribe any recent changes to your sleep habits.*State of Health* Very Good Good Average Declining Date of Last Medical Examination* Month Day Year Results of Last Medical Examination*Physician's Name* First Last Physician's Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please initial here to provide consent for release of medical records if necessaryIf you provide your consent to release your medical records to one of our counselors, please initial the box below. Are you taking any medications?* Yes No Medication ListTo add multple medications, just click on the "+" circle at the end of each line to add an additional line to the list.MedicationReason for TakingLength of Time Have you ever used drugs other than for medicinal purposes.* Yes No If yes, what were they?*Do you ever drink alcoholic beverages?* Yes No How much? How often? Have you ever been arrested?* Yes No What was the outcome? Save and Continue Later Marriage and FamilyThis section will ask you questions about your current marital status and family life.Spouse's Name First Last Spouse's Age Spouse's Occupation Spouse's EducationPlease enter the highest level of education your spouse has achieved. High School College Graduate School Post Graduate Spouse's Religion Marriage Date Month Day Year Husband's age when married Wife's age when married How long did you know each other before marriage? Length of time dating spouse? Length of engagement? Have you been married before?* Yes No If yes, how many times? If you were married before, what caused the end of the marriage?Has your spouse been married before? Yes No If yes, how many times? If your spouse was married before, what caused the end of the marriage?Are you currently separated from your spouse? Yes No If yes, since when? Have you ever been separated in your current marriage? Yes No If yes, how many times?Please enter a number from 1 to 10.Have either of you filed for divorce? Yes No If yes, when? Who filed for divorce? Is your spouse willing to come to counseling with you?* Yes No Uncertain Haven't asked Parenting and ChildhoodThis section will ask questions about both your family as well as your childhood relationship with your own parents.Do you have children?* Yes No Child Information*To add details for additional children, click on the "+" circle at the end of the line to add a new line for the next child.Children's NameAgeGenderLiving (Y/N)From Previous Marriage (Y/N) Were you raised by anyone other than your parents?* Yes No If yes, please briefly explain.Non-Refundable Application FeeThe application fee is non-refundable. This applies to those who decide to be removed from the waiting list. If you are coming for couples or family counseling, you will only have to pay $25 per couple/family–not per person. However, each person coming for counseling will have to fill out his or her own counseling form. If somebody in your group has already paid, we will give you an electronic coupon code to enter on the online counseling form so that it can be submitted without having to pay again. Price: Coupon Total $0.00 Credit CardCard Details Cardholder Name Save and Continue Later Δ Download PDF Intake Form Register for Training Register Sign up for Counseling Sign Up Ask your Questions Contact Make a Donation Donate Rod and Staff Ministries . . .exists to equip churches to strengthen the saints to live above sin, suffering, and circumstance through sanctification (greater conformity to Jesus) unto satisfaction (greater capacity to enjoy Jesus) Soli Deo Gloria. . .