Grace Biblical Counseling Application

Our Goal

Our goal in providing biblical counseling is 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 fully His love for you and His plans for your life.

We’re glad that you’re taking this important step to seek godly counsel.  Jesus promises us, “Come to Me, all you who labor and are heavy laden, and I will give you rest” (Matthew 11:28).  No matter what your situation, this is a time in your life that the God of all creation knows and understands completely and therefore, there is great hope!  This form is helpful for us to start getting to know you and your situation, as well as to communicate these first important points which explain some of our perspectives and convictions which we believe are honoring to God and the best way we can truly be of help to you.

Biblical Basis

We believe that the Bible provides thorough guidance and instruction for faith and life. (II Peter 1:3 and Romans 15:4)  Therefore, our counseling is based solely on scriptural principles rather than those of secular psychology or psychiatry.  In order to support this conviction, we ask that all of those we counsel to either have their pastor or a church leader attend counseling with them or to be regular attendees to our Sunday morning worship services.  These are vital components to your growth in the Lord.

Not Professional Advice

Although some of the pastoral or lay counselors of this church may be licensed in other fields, they do not practice as such in their role as Grace Baptist Biblical Counselors.  In this role, they do not provide the same kind of professional advice and services that they do when they are hired in their professional capacities.  Therefore, if you have significant legal, financial, medical or other technical questions, you should seek advice from independent professionals not associated with Grace Baptist Church.  Our pastoral and lay counselors will be happy to cooperate with such advisors and help you to consider their counsel in the light of relevant biblical principles.  By signing this “Consent to Biblical Counseling” you agree to hold Grace Baptist Church harmless in any and all matters associated with the biblical advice you have received.


Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us.  However, because we are continually training others to be effective counselors we ask that you agree to allow the possibility of counselors in training to be present during your sessions.  Also, there are four situations when it may be necessary for us to share certain information with others: (1) When a counselor is uncertain of how to address a particular problem and needs to seek advice from another pastor or counselor in this church; (2) when a counselee attends another church and it is necessary to talk with his or her pastor or elders; (3) when there is a clear indication that someone may be harmed unless we otherwise intervene; or (4) 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 (see Proverbs 15:22; 24:11; Matthew 18:15-20).  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.

 Resolution of Conflicts

On rare occasions a conflict may arise between counselor and 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 the counselor or with this church as a result of counseling will be settled with mediation within the church according to the principles of scripture and the authority of this local church.

Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body.  If you have any questions about these guidelines, please talk with a pastor.

If these guidelines are acceptable to you, please type your full name below:

  • Application Agreement
  • Personal Information
  • Health Information
  • Religious Background
  • Final Questions

Virtually Sign Below:

Full Name:

Personal Information

Address (Including City, Zip):

With whom do you currently live (Check all that apply)?

If you selected other please specify:

Primary Phone Number:

Email Address:

May we leave a message here?


Birth Date:


Average Hours per Week?

Referred Here By:

Family Information

Name of Spouse:

Age of Spouse:

Spouse's Phone Number:

Spouse's Email Address:

Spouse's Occupation/Employer:

Average Hours per Week?

Date of Marriage:

Your age when married:

Your spouse's age when married:

Is your spouse willing to come for counseling?

Have you ever been separated?

If so, When/How Long?

Have either of you ever filed for divorce?

Give brief information about any previous marriages (Ex-Spouse's name, Year married, Length of marriage, Reason for divorce, Number of kids).

Children information (child's name, age, gender, from a previous marriage?).

How many siblings do you have and which number are you?

Your parents' marital status?

Which of the following words best describe your home of origin? (check all that apply):

Have you ever been arrested?

When/For what?

Health Information

Have you had counseling before?

Have you seen a psychiatrist before?

If yes to either questions please list your age, the duration of the sessions, the counselor/center, the issue(s)/topic(s)/diagnosis and your evaluation of the counseling.

State of current health:

Approximately how many hours of sleep do you get each night?

Describe any recent changes in sleep habits.

Date of last medical examination.

Results of last medical examination.

Current illnesses, injuries, or disabilities:

Are you presently taking any medications?

If yes, please list the medication, dosage, frequency, reason for prescription and the date you began taking the prescription.

Prescribing doctor(s)

Have you used drugs for other than medical purposes?

If yes, when did you use/what did you use/how often and much did you use?

Do you drink alcoholic beverages?

If yes, how often and how much?

Describe your eating habits or changes in appetite:

Please check any of the following physiological that apply to you currently:

Indicate how distressed you are by choosing a number below (1=very little distress; 10=extreme distress):

Religious Background

Do you consider yourself a Christian?

What church are you a member of?

Number of years at church:

Church currently attending:

Pastor's Name:

Permission to consult with pastor?

Church attendance (times per month):

What are you learning through sermons and Bible studies at your church?

Church attended in childhood:

What was your religious experience as a child? What was your home environment like in regards to Christianity, the Bible and the Church?

Do you believe in God?

Have you ever

Do you pray to God? If yes, how often? What do you pray about?

Do you read the Bible? If yes, how often?

Do you have personal devotions? If yes, how often?

Describe your personal devotions:

Please note any recent changes in your spiritual life:

Final Questions

Why are you seeking counseling? What is the problem as you see it?

What have you tried to do already to resolve the problem?

In what way(s) have you contributed to the problem?

What are your expectations in coming here? What can we do for you?

As you see yourself, what kind of person are you? Describe yourself.

What, if anything, do you fear?

Is there any other information that we should know to be able to assist you to the fullest?



3601 Ehlmann Rd

St Charles, MO 63301

(636) 724-4879

Office Hours:
M-W, F: 8:30-5pm

Thur: Closed

Service Times


Sunday School/ABF      9:30am
Main Service                10:45am
Evening Service             5:00pm


Prayer Service               7:00pm