Counseling Support Form – Dakota Baptist Convention

Counseling Support Form

The purpose of this fund is to provide access and assistance in funding for a Christian counselor to be available to pastors, church planters, staff and families. It also is to bring a counselor to the Dakotas to consult, lead workshops in churches and associations, both regionally and state-wide.

The fund is to help financially with the cost of counseling based on financial need utilizing a sliding scale.

Guidelines for this fund:

When a pastor, church planter, staff or family member indicates through the below form, phone call or personal request his desire for a counselor, a confidential request form will be mailed to him.
The form will be directly submitted to the Christian counselor with the counselor being responsible for contacting the person requesting help.
If the person requesting help has a counselor he or she prefers, the DBC Executive will contact the individual and assistance will be arranged.
The DBC will cover the cost of four sessions with a counselor and consider more at the recommendation of the counselor.
After four sessions, the counselee will be asked to assume some part of the cost for counseling on a sliding scale to be determined by financial need.
Any counseling assistance provided will be approved by the chairman and vice-chairman of the Executive Board upon recommendation of the Executive Director. Names will be shared in strictest confidence.

Counseling Support

* Please note that these funds are only available to members of the Dakota Baptist Convention.
Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Is this an emergency?*
- Yes
- No
Do you have a counselor already identified?*
- Yes
- No
Would you like to be referred to a counselor that is provided on a confidential basis by the DBC?*
- Yes
- No
Please read and check that you have read and agree to the following:*
- I understand that if I use a counselor provided by the DBC, the counselor will contact me to begin a counseling relationship.
- I understand that if I use a counselor of my preference, I will submit an invoice for the counselor to be paid to myself for reimbursement.
Please note that all inquiries into counseling will be held in strictest confidence by DBC staff and counselor.
- A confirmation email will not be sent to you due to the sensitive nature of this form unless you check this box.
Are you a real person?
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Counseling Support

* Please note that these funds are only available to members of the Dakota Baptist Convention.

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