Biblical Guidance Marital Information

Your name *

Last name

Email address *

Full Address *

Home Phone Number *

Cell Phone Number *

Work Phone *

Best way to contact you: *

Best day and time to contact you: *

Occupation: *

Gender: *

Age: *

Referred by: *

Family Information

Spouse's Name: *

Spouse's Age: *

Spouse's Address, if different than above: *

Spouse's Occupation: *

Spouse's Business Phone: *

Number of Children from this marriage: *

Gender and ages of children: *

Spiritual Background

Is Calvary Chapel Central Bucks your home church? *

For how long have you been attending? *

Church attendance per month: (check one) *

Do you volunteer in any ministries? If yes, list which ministries? *

Do you currently attend any other ministries (i.e. Home Group, Men's, Womens's, etc.)? If yes, which ones? *

Briefly describe the spiritual background of your spouse: *

Church spouse attends: *

Frequency of spouse's church attendance: *

Do you believe in God? *

Do you pray to God? *

Do you read the Bible? *

Do you have family devotions? *

Do you know for certain that you will go to heaven when you die? *

What is the basis for answering the above question as you did? *

Have you received Jesus Christ personally as your Savior? *

Have you been baptized? *

Personality Information

Have you received counseling in the past? *

Check any of the following words that you believe best describe you: *

Active

Ambitious

Self-confident

Persistent

Nervous

Hardworking

Impatient

Impulsive

Moody

Often Blue

Excitable

Imaginative

Calm

Serious

Easy-going

Shy

Good-natured

Introvert

Extrovert

Likable

Quiet

Leader

Thick-skinned

Submissive

Sensitive

Self-conscious

Lonely

Other

Health Information

Rate your health: *

Date and Results of Last Medical Exam *

Do you drink alcoholic beverages? *

Are you presently taking medication? *

Have you used drugs for other than medical purposes? *

Have you ever had a severe emotional upset? *

Please check any of the following general problem areas in your marriage: *

Not resolving conflicts

Selfishness

Credit or debt problems

Interference from in-laws

Possessiveness of jealousy

Pornography

Gambling abuse

Depression

Anger

Lack of communication

Conflicts over decision-making

Struggling in your Christian walk

Unrealistic expectations

Drug abuse

Alcohol abuse

Sexual frustration

Unforgiveness

Adultery

Lack of involvement or discipline problems with children

Over committed outside the home - job, sports, etc.

Marriage Problem Information

Please list the four most severe problems you are having in your marriage: *

What have you done to try to resolve these problems? *

Have you ever had marriage counseling for these problems?

Are you going to a counselor right now? *

Is your spouse willing to come in for Biblical Guidance? *

Have you ever been separated? *

How long have you been married? *

How long did you know your spouse before marriage? *

How long were you steadily dating your spouse before marriage? *

How long were you engaged? *

Have you or your spouse been married before? *

Side By Side Ministry

In order to best serve you, we would like to advise you regarding the kind of support that you may expect to receive from the Side By Side Ministry staff of Calvary Chapel Central Bucks (CCCB). It is our desire to point you towards Jesus Christ as the ultimate Counselor and to apply the principles of Scripture to your life through prayer and study of the Bible.

Side By Side pastors and support staff are not professional counselors and we are not licensed or trained in any counseling, medical or psychological disciplines. While we do not provide professional counseling, we may recommend you seek counseling with someone who is better suited and equipped to meet your needs.

We do desire to support you as you seek to make Biblical changes in your life. We believe developing a strong personal relationship with Jesus is the best way to find healing and growth. Side By Side Ministry exists to provide short-term Biblical direction for people struggling with life’s issues, and who are willing to do the hard work of change.

Side By Side is a confidential ministry offering hope to those who regularly attend CCCB. We desire to provide a safe place to share your concerns and yet we also recognize that “everything should be done in a fitting and orderly way.” 1 Corinthians 14:40. Therefore, depending on the situation, there may be Biblical reasons to share information with the Side By Side leadership team and pastoral staff when/if necessary. Likewise should state law require disclosure of information shared, we must comply with those legal requirements.

Side by Side Ministry Policies & Waiver

1. All Side By Side Ministry support staff are spiritually mature and Biblically knowledgeable Christians who will act as a conduit with the pastoral staff.

2. Nothing said or implied should be taken in any way as advice to disregard a doctor’s medical advice, prescriptive regimen or prescribed directions.

3. Those involved with the Side By Side ministry are to comply with our confidentiality statement.

4. “Support people” are not to discuss any Side By Side interactions with anyone who is not a pastor or on the Side By Side leadership of CCCB. Any contact with a party outside of the above mentioned may be initiated only after seeking informed consent of the person seeking help and Side By Side leadership, or through pastoral determination.

5. We will carefully guard the information you entrust to us, however, there are five situations when it may be necessary for us to share certain information with others:

A. When a Pastor/Support Person is uncertain regarding how to address a particular problem and needs to seek advice from another pastor or elder in this church;

B. When a person attends another church and it is necessary to speak with his or her pastor or elders;

C. When there is a clear indication that someone may be harmed unless others intervene;

D. 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;

E. When a crime has been committed (see Proverbs 15:22, Proverbs 24:11, Matthew 18:15-20, Deuteronomy 13:6-8).

6. Confidentiality is an individual privilege, however, in order to prevent dissension and confusion, this privilege may be waived should the person seeking help discuss the privileged matters in the presence of third parties or share the content of those discussions with a third party after the Side By Side session. The content shared in Side By Side interactions, which is discussed outside of the Side By Side Ministry, may act as a waiver of the privilege of confidentiality.

7. Under Pennsylvania state law, we are required to report, to the appropriate legal authorities, any information that would indicate a situation involving child abuse, that endangers the person seeking help, or that may bring harm to anyone else.

8. If an individual's life circumstances might negatively affect the ministry they’re involved with, or if serving in that ministry distracts them from resolving the matter, a pastor will determine if the individual needs to be asked to temporarily step down from their church responsibilities.

9. Side By Side is a volunteer ministry and therefore no compensation will be received for help given. Should the need for professional counseling arise, individuals will be referred to outside providers.

10. Those seeking support from Side By Side agree to:

A. Be open and honest when speaking with a Side By Side support person;

B. Be diligent in reading God’s Word and following through with advice given;

C. Commit to regular participation in worship, Bible study, & prayer at CCCB.

11. Failure to comply with the above commitments may result in discontinuing the support offered by Side By Side.

12. Should anyone involved in the Side By Side Ministry violate these policies, the Side By Side leadership staff should be notified as soon as possible.

AGREEMENTS ~ PLEASE READ THE FOLLOWING PARAGRAPHS CAREFULLY

In order to offer distinctively Bible-based assistance and to protect the ministry from unwarranted legal action, we ask persons seeking help to agree to the following: In consideration of the waiver of any fee for the support I receive, and with the intent to be legally bound, I waive and release any claim or case action against Calvary Chapel of Central Bucks, it's staff, or my support person arising from anything whatsoever connected with the Biblical instruction or support I am receiving without limiting the generality or the foregoing any claim for negligence of malpractice.

I have read and understand the policies of the Side By Side Ministry of CCCB and agree to submit to them. I also understand that I am NOT receiving paid professional counseling, but I am asking for Biblical spiritual advice.

By entering my full name below, I am electronically signing this form to confirm I am in agreement with the above policies.

Type full name below *

Date of Submission *

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Calvary Chapel Central Bucks
office@cccbucks.org
215-822-4012