Pastoral Counseling Intake Form for Parents.

Confidential Questionnaire – To Be Completed by the Parent/Guardian Facilitated by Pastor Terry (See qualifications below).

🧑‍⚕️ IMPORTANT NOTE

Please be advised: I am not a Licensed Professional Counselor or State-Certified Therapist. I offer Biblically Principled Life Guidance and Pastoral Counseling based on more than 45 years of ministerial and family counseling experience. My work is rooted in biblical principles and helps individuals develop what to Believe and how to Behave in light of God's Word. My goal is not to diagnose or treat any disorder but to walk alongside your child with grace, wisdom, and encouragement.

👩‍👦 Parent Information

Your Full Name:

Relationship to Child:

Phone Number:

Email Address:

Preferred Contact Method & Time:

👦 Child Information

Child’s Full Name:

Nickname (if any):

Age:

Date of Birth:

Current Grade in School: Does he attend school in person or online? Church involvement (if any):

🧩 Presenting Concerns

Please briefly describe what led you to seek outside guidance for your son:

What are your primary concerns at this time?

Has your child experienced or currently been evaluated for:

•  Autism or Autism Spectrum Disorder (ASD)

•  ADHD or ADD

•  Anxiety or Depression

•  Behavioral challenges at home or school

•  Speech or communication issues

•  Sensory sensitivities

•  Social difficulties

•  Other (please explain):

  
  

Have any of the above been diagnosed by a professional? If yes, please share any official diagnosis and approximate date:

💬 Social and Emotional Insight

How would you describe your son’s personality?

How does he typically handle stress or change?

Does he have potent emotional triggers (fears, situations, sensitivities)?

What are his strengths, talents, or interests?

Does your child currently have a father figure or male mentor?

🧠 Spiritual and Moral Development

Has your child ever:

• Asked questions about God or faith?

• Expressed interest in prayer or Bible reading?

• Attended Sunday School or youth programs?

• Have you been exposed to Biblical teaching at home?

  
  

Please describe briefly:

What spiritual or character values are most important for you to see developed in your son?

Do you want this mentoring relationship to focus on any specific topics or issues? (e.g., identity, honesty, respect, boundaries, friendships, emotional regulation).

🔐 Confidentiality & Boundaries

Do you understand that this is not a clinical counseling service but a Biblically based mentoring relationship focused on life principles, emotional support, and character growth?

•  Yes, I understand and agree.

  
  

Do you give permission for your son to meet with Pastor Terry one-on-one (in person or virtually) for spiritual mentoring and life guidance?

•  Yes, I give permission.

  
  

How often would you like to receive general updates (if any) about your child’s progress?

•  Weekly

•  Monthly

•  Only if there is a concern

•  No updates unless requested

✝️ My Qualifications to Serve Your Family

I, Pastor Terry, am not a licensed counselor. However, I have served as a Marriage & Family Pastoral Counselor for over 43 years, including as a Police Chaplain, Baseball Chaplain, and long-term Senior Pastor. I am a 100% Service-Connected Disabled Veteran and am now managing life challenges, including PTSD, cancer, alcoholism, divorce, and remarriage.

I hold academic degrees in Theology, a Master of Arts, and a Doctorate from various Christian accrediting bodies, giving me a deep well of Biblical insight and empathy to walk with families through complex seasons.

My mission is to help young people build their lives on God's Word, discovering their identity, purpose, and strength in Christ.

✍️ Parent Signature

Signature: _____________________________________Date: _____________________