Registration — Biblical Counseling of Arizona

Register for Counseling

You are not meant to walk alone. Our counselors will demonstrate God’s gracious pursuit of you in relationship: listening and walking alongside of you in your struggle with encouragement and understanding.
Name *

First Name Last Name
Age *
Gender *
Email *
example@example.com
City and State *

Street Address

Street Address Line 2

City State / Province
Phone Number *
Please enter a valid phone number.
Where do you attend church? *
If you attend church, please let us know which one.
Type of Service *
Reason for Counsel *
Is there anything else you'd like us to know?

Statement of Understanding

Biblical Counseling of Arizona
I request to receive services from Biblical Counseling of Arizona and understand it is a Lay Ministry. I also understand and agree, as a condition of receiving these services, that the individual I will be meeting with is under the supervision of their own pastor and my BCA counselor:
- Is not a lawyer, clergyman, Ph.D. level counselor, or doctor.
- Is not someone with whom communication is legally privileged from disclosure,
- Is committed to providing biblically based guidance to me, but cannot provide me with professional legal, mental, or medical services.
I fully understand and agree that my communication is not privileged and is not protected from being revealed to others. That is, what I disclose to the counselor may later be forced to be disclosed to a Judge, to a law enforcement officer or to an opposing party or to their attorney. I release Biblical Counseling Arizona from any liability for such disclosure.

I also understand that Biblical Counseling of Arizona encourages and advises me to consult my lawyer, Ph.D. level counselor, clergyman or doctor for any professional services or counsel needed of which I intend to be legally privileged from disclosure.
Name *

First Name Last Name
Signature *

Clear

Goal of Biblical Counseling
Our specific goal in counseling at BCA is to walk beside you for a period of time, reveal and/or remind you of the God of scripture and reconnect you with members of your body under your pastoral care. Total ministry of a church includes sound preaching, teaching and fellowship that biblically supports you with accountability for daily, weekly, monthly, yearly walking with Christ.

If you are not attending church or if your church is not structured to provide the kind of support received at Biblical Counseling of AZ, we will encourage you to attend a Bible-believing church in the area on a weekly basis.

I understand there will be charges for services rendered. All extra materials needed I will be responsible to pay including books, pamphlets, and other materials my counselor may offer. This is not considered a tax deductible donation.

By signing below, I acknowledge: that I sign this Statement of Understanding & Goal of BCA voluntarily, free from deception, undue influence, coercion, or duress of any kind, that I have given careful and mature thought to signing this statement; that I have carefully read each provision of this statement; that I fully and completely understand each provision of the statement; and that I have the right to consult with legal counsel if I choose to prior to signing
this statement.
Name *

First Name Last Name
Signature *

Clear

Parental Consent to Counsel Minor
Is this counseling for a minor? *

Yes No
I am the parent or legal guardian of the minor child whose name appears below. I have custody of my child and am under no court order which would prevent me from seeking counsel on my child's behalf.

I have read and agree to be bound by the terms in the Biblical Counseling of Arizona "Statement of Understanding" and "Goal of Biblical Counseling of Arizona" forms incorporated by reference herein. I understand that all counseling provided my child will be based on biblical principles which may or may not be in accordance with modern psychological standards. By requesting counsel from Biblical Counseling of Arizona, I intend to exercise my fundamental right to instruct my child in the principles of the Christian faith.

By affixing my signature below, I give Biblical Counseling of Arizona permission to counsel my child.
Minor's Name
Minor's Date of Birth
Name of Parent or Guardian
Parent/Guardian Signature

Clear
Should be Empty: