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Please complete the application provided below. After submitting an application, a staff member will get back to you in order to schedule your appointment. 

(860) 618-0010


Are you presently in crisis?
Do you prefer to schedule an evening or daytime appointment?
Rate your physical health:
Do you (or have you in the recent past) use drugs for other than medical purposes?
Have you ever had a severe emotional upset?
Have you ever had psychotherapy or counseling?
Have you ever been hospitalized for either psychiatric or medical purposes?
Have you ever been arrested or incarcerated?
Have you ever experienced hallucinations, delusions, or delirium?
Are you adopted?
Are you willing to sign a release of information form so that your counselor(s) may write for helpful social, psychiatric, or medical reports?
Have you ever felt as though people were watching you?
Are your parents married?
Do you have siblings?
What is your monthly church attendance?

Please carefully read our Confidentiality Agreement below. 

Confidentiality Agreement

On the date this form is completed, the parties, a  Counselor (or Counselors) of Northwest Hills Community Church or(and) its ministries (hereinafter designated Counselor) has agreed to provide counseling services to you, (hereinafter designated Counselee) on the following terms and conditions: 


Whereas the parties acknowledge that the counseling services provided are Biblically based and are not part of a licensed discipline governed/regulated by any governmental agency, and; 


Whereas the parties acknowledge that the counseling services and confidentiality of the same is conditional for which the Counselee gives authorization and full release of Counselor upon the disclosure of information should contingencies arise that require the same as outlined herein below; Now therefore, the parties further agree as follows: 


Confidentiality – The counselor is very sensitive to the issue of confidentiality. Confidentiality is crucial to an effective and trusting counseling relationship and the counselor will carefully guard the information Counselee entrusts to him/her. There are situations, however, in which the discipleship Counselor may believe that it is wise or mandated (Biblically and/or legally) for them to share certain information with others. There are five (5) situations where it may become necessary for Counselor to share certain information with others. By signing this agreement Counselee acknowledges that they are pursuing a form and course of counseling that is in conformity with their faith and Biblical orientation and desire the same to be provided and is being provided in relation to the church community they have voluntarily engaged and further authorizes the Counselor to share information with others in the following limited circumstances: 


• When a Biblical Counselor is uncertain how to address a problem and needs to seek advice from another pastor or counselor. The specific name and particular information will be generalized so that the other consultant doesn’t know who the Counselor is counseling (Prov. 11:14; 24:6). 


• When there is concern that someone may be harmed and abused unless government officials intervene (Rom. 13:1-7).


•Adult and Domestic Abuse: If we have reasonable cause to believe that an adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency which provides protective services. If you express a serious threat or intent to kill or seriously injure an identified or readily identifiable person or group of people, and we determine that you are likely to carry out the threat, we must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent and/or appropriate criminal agencies. 


• Abuse: According to the State of Connecticut’s mandatory reporter laws (CT Gen. Stat. §17a-28; 17a-101), if we have reasonable cause to suspect abuse of children (i.e., anyone under the age of 18 or any DCF client under the age of 21) with whom counselor comes into contact, we will report this to the appropriate governmental agencies.  


• When counseling someone who is under familial authority (e.g. wife to husband, child to parent) the counselor may encourage the Counselee to inform their familial authority and/or the Counselor may inform them (Eph. 5:22- 6:4). 


• When a person refuses to renounce a particular sin, and seeks to continue in counseling with the counselor, it will become necessary to seek the assistance of others in the Counselee’s church to encourage repentance and reconciliation and/or to begin the process of church discipline (Prov. 15:22, 24:11; Matt. 18:15-20).  


• When discussing the information with the observers sitting in on the counseling sessions to assist the Counselor or for training purposes.  


Please be assured that our counselors strongly prefer not to disclose your personal information to others (if not needed), and they will make every effort to help you find ways to resolve a problem as privately as possible.  


By signing below you consent to our Confidentiality Agreement:

Please carefully read our Consent to Care form below.

Consent to Care 


Our Goal: The mission of our counseling ministry is to equip you to meet the challenges of life by the transforming power of Jesus Christ for the glory of God. We offer counseling free of charge. While counselees may donate to the ministry, this is not expected or required as a condition of counseling. You have no express or implied obligation to pay fees for the counseling you receive through our ministry.


Biblical Basis: The counseling we offer is strictly Christian in nature, conducted under the authority and leadership of the church. We believe that God, through his revelation in the Old and New Testaments of the Bible, has provided his people with thorough guidance and instruction for faith and life (2 Tim. 3:16-17; 2 Pet. 1:3-4). Our counseling is based solely on scriptural principles. We do not employ nor integrate the teachings and methods of modern psychology or psychiatry.


Our Counselors: Our counselors are not trained nor licensed as psychotherapists or mental health professionals, and under Connecticut law (CT General Statutes 383c §20-195bb) no such licensing is required. We do not provide referrals to secular counselors or those who integrate secular counseling into the Christian faith. All of our counselors have undergone training in biblical counseling and either possess certification with the Association of Certified Biblical Counselors or are supervised by those who possess such certification.


Other Professional Advice: If you have significant medical, legal, financial, or other technical questions, you should seek advice from a competent independent professional. Our counselors may be able to provide a referral to a relevant professional but such a referral does not imply any professional or legal contract. Our counselors will cooperate with such advisors and help you to consider their counsel in the light of scriptural principles. More specifically, we urge our counselees to properly care for their physical bodies and to seek proper medical treatment for all physiological problems. Our counselors will assist you in responding to such problems in a godly manner, but our counsel is not intended to replace the services of a qualified physician where organic problems are present or where medication has been prescribed.   


By signing below you acknowledge the purpose, scope, and basis of our counsel and consent to care: 

Thank you for submitting your counseling application. A staff member will get back to you soon to schedule an appointment. 

Counseling Application Form

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