Your First Name *

Your Last Name *

Your Phone *

Your Email Address *

First Name *

Last Name *

Phone *

Email Address *

Gender * --Select-- Male Female

Age (years old)

Campus * --Select-- Community (Does not attend Gospel City Church) Gospel City Church

Service Counselee Attends --Select-- Does not attend Not Known Sunday 11:00 AM Sunday 9:00 AM

Frequency Of Church Attendance --Select-- Consistent Does Not Attend Irregular Never misses Rarely

Currently Serving --Select-- Yes No

Ministry Counselee Serves In * Parking Team    Welcome Team    Children's Ministry    Student Ministries    Worship Team    Small Group Leader    Other   

Small Group Attendance * --Select-- Consistent Does Not Attend Irregular Never misses Rarely

Small Group Position Spiritually (GPS) * --Select-- Superficial Authentic Transparent Vulnerable Unknown

Severity * --Select-- 1 - Wisdom issue / stress related / everyday problem 2 3 4 5 - Moderate conflict / distressed but functioning / more complex issues 6 7 8 9 10 - Crisis / stronghold sin / significant suffering

Why did you choose this score *

Ownership * --Select-- 1 - Wisdom issue / stress related / everyday problem 2 3 4 5 - Moderate conflict / distressed but functioning / more complex issues 6 7 8 9 10 - Crisis / stronghold sin / significant suffering

Why did you choose this score *

Support * --Select-- 1 - Wisdom issue / stress related / everyday problem 2 3 4 5 - Moderate conflict / distressed but functioning / more complex issues 6 7 8 9 10 - Crisis / stronghold sin / significant suffering

Why did you choose this score *

Total

Why Is BSC The Right Next Step?

Has the small group leader contacted anyone on staff? * Yes    No   

To whom on staff has the small group leader spoken?

What Is The Presenting Problem *

How Long Has The Presenting Problem Existed? *

What Is The Observable Fruit? Select All That Apply * Isolation    Anger    Discontent    Anxiety    Despair    Fear    Foolishness   
Other   

Why are you referring the counselee to Biblical Soul Care (BSC)? How do you think BSC can help? *

What have you done to assist the counselee with the current situation? *

Which specific Scriptures have been asked to be applied to the counselee's life and current situation? Has homework been assigned to the counselee? If yes, what specifically (and was it completed)? *

How have you and other leaders (e.g. small group leader) collaborated to help the counselee with the current situation? *

Has a Pastor/Director been consulted to assist with overseeing this situation and been given the opportunity to shepherd? *

Please feel free to add any other information that may assist BSC in serving the counselee *

Marriage Counseling This referral is for marriage counseling