Marriage Counseling Request

Marriage Counseling Request

Please complete one application per couple. The information in this form is confidential and will only be viewed by specific leaders in this ministry.
Your Information
Name

First Last
E-mail
Phone Number

- Area Code Phone Number
Birth Date

Month Day Year
Gender
Occupation
Your Fiance's Information
Name

First Last
E-mail
Phone Number

- Area Code Phone Number
Birth Date

Month Day Year
Gender
Occupation
Couple's Information
How long have you two attended The Paradox Church?
What is your current partnership status at The Paradox Church?
How long have you been a partner?
Have you attended Preparing for Marriage class, which is recommended for the Premarital Counseling process. *

Yes No, but I am registered for the upcoming class.. No
Please choose the following option that most closely describes your involvement in community at The Paradox.
Who leads your City Group?
What is their name?
Wedding date *

Month Day Year
Location of wedding *
Will you be requesting a minister of The Paradox to officiate the wedding? *
We cannot guarantee an officiant from The Paradox will be available, but will inquire availability based on your request and work to communicate availability in timely manner.
If so, who is your first choice?
Availability may vary, so please select up to three ministers.
Who is your second choice?
Availability may vary, so please select up to three ministers.
Who is your third choice?
Availability may vary, so please select up to three ministers.
Please use this space to communicate any further information you want us to know:

Physical Boundaries
As a participant in the marriage process, you will be asked to covenant with us in abstaining from sexual involvement during your engagement. Are you willing to accept God's word that sex outside of marriage is sinful and agree to this covenant?
Why or why not?

Are either of you currently seeing a licensed counselor, psychologist, psychiatrist or a pastor at The Paradox or volunteer counselor?

Yes No
Counselor's Name

First Name Last Name
Counselor's Phone

- Area Code Phone Number
Why are you seeing this counselor?

The Role of Spiritual Counseling & Consent Agreement

Spiritual care is provided by The Paradox Church for the expressed purpose of providing biblical help for those who seek it. We believe Jesus came to bring healing to the way we think, behave and feel. He declared: "I came to bring healing to the brokenhearted, preach deliverance to the captives, and recover the sight to the blind, to set at liberty them that are bruised" (Luke 4:18). The elders and others who provide spiritual care desire to help people overcome spiritual or emotional concerns by applying spiritual principles to areas of need. They are exempt from the laws regulating professional counselors under RCW 18.19.040 (6) (counseling under the auspices of a church and counseling provided without mandatory charge). In most cases, they are not professionally trained, nor registered, licensed, or certified by the State of Texas or a national certifying body. Should an elder or other person providing pastoral care also happen to be a registered counselor with the State of Texas, the spiritual counseling provided by such person at The Paradox Church is not being provided in their capacity as a registered counselor. By signing below, you acknowledge that you will be receiving spiritual counseling. Spiritual counseling through The Paradox Church is not a substitute for professional care by a psychologist, psychiatrist, medical doctor or other health care provider, and staff at The Paradox Church are not professionally trained to diagnose or treat mental illness or other medical conditions. Therefore, it is your sole, exclusive responsibility to seek professional care and you agree it shall not be a responsibility of The Paradox Church to make such a referral. Work Agreement - In seeking help, you agree you will make a good-faith effort at personal growth and engage in the pastoral care process as an important priority at this time in your life. You agree that if you fail to do your work, or if you do not appear to be benefiting from the pastoral care, we may terminate the spiritual counseling relationship. The number of sessions required for your situation depends on the type and severity of the problem, the amount of work you are willing to do and various other factors. It is customary to begin with six sessions then evaluate progress and investigate alternative resources. Do not be discouraged if you do not feel as if you are making progress as quickly as you’d like. Should you and your counselor determine that you are unable to make sufficient progress after two to six one-hour meetings, you will be directed to a listing of qualified counselors for referral. You agree you will be responsible for paying the fees of any professional counselor or therapist. Children under 18 years old will not receive pastoral care without the written consent of their legal parent or guardian. Cancellation/ No-Show Policy - It is expected that you give a minimum of 24 hours notice if you will be unable to attend your appointment. If there are extenuating circumstances on the day of the appointment that will prevent you from attending, call the front desk and let them know immediately. If you are more than 10 minutes late to an appointment, the session will be canceled and will need to be rescheduled. Failure to follow this policy prevents The Paradox Church from being able to provide spiritual care, and could result in The Paradox Church denying future care. Confidentiality - The staff at The Paradox Church will attempt to preserve the confidentiality of any matters discussed in a counseling session. However, confidentiality will not apply: 1. When there is evidence of abuse of a child or vulnerable adult, or where disclosure is required by law. 2. When your pastor or counselor feels a need to discuss your case for consultation purposes with his/her supervisor, peers, professionals, or elders/pastors who may be a resource involved in your situation. 3. When there is contemplation of or commission of a crime or harmful act. 4. When there is a subpoena or other legal process. 5. When you or your legal representative authorize disclosure of information. 6. In other circumstances where the pastor or counselor deems it necessary to disclose the information.
I have thoroughly read and agree to the foregoing policies regarding pastoral care provided at The Paradox Church. I hereby release and hold harmless The Paradox Church, its directors, officers, employees, and volunteers from any and all liability, claims, and/or expenses related to or arising from any pastoral care or counseling received (or not received).
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Today's Date

- Month - Day Year
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Marriage Counseling Request

Your Information

Your Fiance's Information

Couple's Information

Physical Boundaries

The Role of Spiritual Counseling & Consent Agreement