Counseling Client Intake Form

Counseling Client Intake Form

Please complete all parts of all sections
SECTION 1: CLIENT INFORMATION

Thank you for providing us this important information about yourself
Client's demographic (please select one) *

Adult Individual (18 > years of age) Adult Couple (both parties need to complete a separate form) Teen / Adolescent (13 - 17 years of age) Child ( < 13 years of age)
Client's name *

First Name Last Name
Parent / Guardian's name (if client is under 18 years of age) *

First Name Last Name
Client's email *
example@example.com
Parent / Guardian's email (if client is under 18 years of age) *
example@example.com
Client's date of birth *

Month Day Year
Client's age *
Client's mobile number *

Area Code Phone Number
Parent / Guardian's mobile number (if client is under 18 years of age) *

Area Code Phone Number
Client's home address *

Street Address

Street Address Line 2

City State

Zip Code
Client's job / employer *
Client's marital status (please select one) *

Single Divorced Widowed Dating Living together Engaged Separated Married
What is your spouse's name? *
How long have the two of you been married? *
Have you ever been married to anyone other than you current spouse? *

No Yes
How many previous marriages have you had? *
What is your partner's name? *
How long have the two of you been together? *
Do you have any children? *

No Yes
Please provide the name and age of each child *
Body, Spirit, & Soul

This section is to be answered by the client, even if under 18 years of age
I believe my physical health is (please select one) *

Excellent Good Average Fair Poor
I believe my spiritual health is (please select one) *

Excellent Good Average Fair Poor
I believe my soul health is (please select one) *

Excellent Good Average Fair Poor
What religion, denomination, or other belief system were you raised in, if any? *
Do you currently attend a church? *

No Yes
What is the name of that church? *
How often do you attend that church? (please select one) *

Every time the doors are opened Regularly Frequently Occasionally Not very often Christmas and Easter only
If you were to die today, do you know for sure you would go to heaven? (please select one) *

No Not sure No one can know that for sure Yes
If no, why not? If yes, why? *
Family of Origin
What is your father's name? *
Is he your biological father? *

No Yes
Is he still living? *

No Yes
What was his occupation when you were a child? *
What is your mother's name? *
Is she your biological mother? *

No Yes
Is she still living? *

No Yes
What was her occupation when you were a child *
Were you raised by both of your biological parents in the same home? *

No Yes
What caused your parents to not be together when you were a child? (please select one) *

Divorce Separation Death I never knew one or both of my biological parents
Do you have any step-parents? *

No Yes
How many siblings did you have while growing up? *
What position were you in the birth order of your siblings (i.e. 2/4)? *
How old were you when you left home and began living on your own? *
Current Issues & Concerns
Please click in the box next to items on this list that have affected your quality of life WITHIN THE PAST 6 MONTHS *

Grief Depression Marriage problems Issues with children Homelessness Bitterness Anxiety Issues with parents Compulsiveness Sexual Concerns Adultery Impotence / ED Nervousness Fear Homosexuality Self-doubt Financial stress Suicidal thoughts Guilt Anger with God Loss of temper Suicide attempt Crying spells Loss of self-respect Moodiness Weight concerns Loneliness Loss of meaning Excessive worry Excessive stress Excessive fear Low self-esteem Drug use Drug abuse Drug addiction Alcoholism Cigarette use Smokeless tobacco use Self-harm / cutting Unforgiveness Abandonment Rejection Codependency Legal issues Sexually abused Emotionally abused Physically abused Spiritually abused OCD Pornography Hopelessness Hatred
Section 1 Confirmation
By typing my name here, I am confirming that the personal information I have provided in this CLIENT INFORMATION section above is true and accurate to the best of my knowledge (if client is under 18 years of age, parent or guardian should type their name here) *

First Name Last Name
SECTION 2: CLIENT AGREEMENT

Thank you for reading and completing each section as indicated
Counselor Credentials
I have been informed and understand that all counseling, training, testing, and other counseling-related services are solely provided by an individual or individuals whose focus will be to seek healing and restoration through God’s word, prayer, and godly counsel, and to teach me, the client, how to live in God's best for my life and relationships. I understand that my counselor is a Licensed and Ordained Minister and is Certified/Licensed by the National Christian Counselors Association. My counselor is not a therapist or practitioner licensed by the State of Kentucky, and they do not intend to portray themselves as such. I trust that my counselor is held to a standard of ongoing training, credentialing, ethical practice, and professional excellence. I understand that I have the right to request proof of my counselor's credentials at any time. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Client Confidentiality
I understand that all counseling-related communications, records, and contacts with Life Training Christian Counseling will be held in strict confidence and made accessible only to those on the Life Training counseling team who are involved in my care. In accordance with state law, information regarding my counseling with Life Training Christian Counseling may only be released in instances when:: 1) as the client, I sign a written release of information document indicating informed consent to such release, 2) as the client, I expresses serious intent to harm myself or someone else, or 3) there is evidence or reasonable suspicion of my abusing a minor child, elderly person (sixty-five years or older), or dependent adult. My counselor and Life Training Christian Counseling will do everything possible to inform me of any mandated disclosures of information. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Client Participation
I, as the client, agree to make a good-faith effort to grow in soul and spirit as facilitated by my counselor, and engage in the counseling process as an important priority at this time in my life. My gain is the most important objective in my seeking Christian counseling. I understand that suspension or termination of counseling, or referral to another provider, shall be discussed between me and the counselor in the event that: 1) I exhibit a pattern of behavior that reveals disinterest or lack of commitment to the counseling process, or 2) there is any unresolved conflict or impasse between me and the counselor. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Section 2 Confirmation
By typing my name here, I am confirming that I have read, agreed to, and initialed the information in each part of the CLIENT AGREEMENT section above. (If client is under 18 years of age, parent or guardian should type their name here) *

First Name Last Name
SECTION 3: FINANCIAL AGREEMENT

Thank you for reading and completing each section as indicated
Regular Session Fees
I understand that the initial session with my counselor will serve as an informal interview - like a test drive - to allow both me and my counselor to decide if the relationship feels right. Although it is the desire of Life Training that every client choose to continue with additional sessions after this initial interview, there is certainly no obligation on the client's part to do so. I understand that the fee for each session - including the initial interview - will be the standard rate of $100 per session. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above.
APS Temperament Profile
I understand that I will be asked to complete the Arno Profile System (APS) temperament profile. There is no cost to me for this assessment, but I understand it is still very important information that will allow my counselor to individualize my care. The APS is a 60-question multiple-choice questionnaire, and is an important diagnostic tool that will provide my counselor an analysis of my God-given, inborn characteristics. This will be used by my counselor as important baseline information for counseling. My counselor will discuss this in greater detail at one of my first few appointments. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Cash-Pay Only
I understand that Life Training Ministries, Inc. is a 501(c)(3) non-profit ministry and not a provider of psychological or mental health care. Because Life Training is a faith-based not-for-profit organization, they are not able to bill my insurance carrier. I understand that, should I elect to submit a claim in hopes of receiving reimbursement from my own health insurance, this will be at my own discretion, and Life Training cannot be held responsible or liable for the outcome of that claim. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Payment Methods
I understand that I am responsible to make full payment for each session at the time of each session. My client fees can be paid by cash, check, or credit/debit card at the time of the session. There will be a QuickBooks service fee of 3.15% added to all payments that I make by credit/debit card. I will be emailed a QuickBooks receipt after each payment is submitted. My account cannot be in arrears when I schedule additional counseling sessions. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Late Cancellations and No-Shows
I agree to attend and be punctual for all scheduled appointment times. In the event that I no-show an appointment or cancel a scheduled appointment with less than 24-hours’ notice, my credit card information on file will be billed the full fee for that missed session. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Returned Check NSF Fee
I understand that a $25 fee will be applied to my Life Training account for any NSF payments. (If client is under 18 years of age, parent or guardian should type their initials here) *
Initial here to indicate your understanding and agreement with above
Credit Card Authorization
We ask that each client have their credit card information kept confidentially on file in our office to be utilized only as the client directs (please choose one): *

OPTION 1: I will print and fill out the online Credit Card Authorization Form located at https://lifetrainingcounseling.org/credit-card-authorization-form/ and bring it to my initial appointment to be kept in my file. I authorize that all of my counseling sessions from that point forward, as well as any late cancellations or no-shows, be charged by to this card by Life Training Christian Counseling. OPTION 2: I will print and fill out the online Credit Card Authorization Form located at https://lifetrainingcounseling.org/credit-card-authorization-form/ and bring it to my initial appointment to be kept in my file. I plan to pay at each session by cash or check, but authorize that this card be charged by Life Training Christian Counseling for any late cancellations or no-shows that I may have. OPTION 3: Because I don't have access to a printer, I will complete the Credit Card Authorization paper form upon arrival at my initial appointment. I understand this signed form will be kept in my file. I authorize that all of my sessions from that point forward be charged by to this card by Life Training Christian Counseling. OPTION 4: Because I don't have access to a printer, I will complete the Credit Card Authorization paper form upon arrival at my initial appointment. I understand this signed form will be kept in my file. I plan to pay at each session by cash or check, but authorize that this card be charged by Life Training Christian Counseling for any late cancellations or no-shows that I may have.
Section 3 Confirmation
By typing my name here, I am confirming that I have read, agreed to, and initialed the information in each part of the CLIENT AGREEMENT section above. (If client is under 18 years of age, parent or guardian should type their name here)

First Name Last Name
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Counseling Client Intake Form

SECTION 1: CLIENT INFORMATION

Body, Spirit, & Soul

Family of Origin

Current Issues & Concerns

Section 1 Confirmation

SECTION 2: CLIENT AGREEMENT

Counselor Credentials

Client Confidentiality

Client Participation

Section 2 Confirmation

SECTION 3: FINANCIAL AGREEMENT

Regular Session Fees

APS Temperament Profile

Cash-Pay Only

Payment Methods

Late Cancellations and No-Shows

Returned Check NSF Fee

Credit Card Authorization

Section 3 Confirmation