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 (each please complete separate forms) 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 spiritual health is (please select one) *

Good Fair Poor
I believe my emotional health is (please select one) *

Good Fair Poor
I believe my physical health is (please select one) *

Good Fair Poor
My current financial status is (please select one) *

Good Fair Poor
Have you experienced overwhelming sadness, grief, depression, or anxiety? (please select one) *

Never More than a year ago In the past year In the past six months In the past week Today
If you identity as a Christian, which denomination best describes you? (please select one) *

Catholic Orthodox Anglican Protestant Presbyterian Baptist Southern Baptist Lutheran Methodist Pentecostal Non-denominational Not sure Not a Christian
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) *

Regularly Occasionally Rarely Christmas and Easter only Never
If you consider yourself a Christian, which of these options BEST describes you? (please select one) *

I believe in God I was baptized as an infant I accepted Jesus when I was a child I think I'm a good person I try hard to become a better person I believe many Christians are hypocrites I claim God's promises for my life I am a fully committed follower of Jesus
Which option BEST describes your prayer life? (please select one) *

I never pray My prayers typically consist of me asking God to act on my behalf I only pray when I'm in a crisis or a situation that is outside of my control My prayers consist primarily of me thanking God for things Most of my prayers are for people other than myself I often pray that God will change something in me My prayers typically consist of me asking God to forgive me for something My prayers tend to center around me worshiping and praising God
Family of Origin
What is your father's name? *
Is he still living? *

No Yes
Is/was he your biological father? *

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

No Yes
Is/was she your biological mother? *

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 One parent was absent
Do you have any step-parents? *

No Yes
How many siblings lived in your childhood home with you? *
What position were you in birth order of these siblings (i.e. 2/4)? *
How old were you when you left home and began living on your own? *
Goals for Counseling
What is the the primary issue that has led you to seek counseling at this time? *
What is the outcome you hope counseling will provide? *
What best describes the nature of the counseling you are seeking? (please select one) *

Band-Aid -- to help me deal with a small life issue Basic first aid -- to treat wounds and hurts I've experienced in my life Emergency room -- to save my life before it's too late Heart surgery -- to help me deal with the brokenness inside me Referee -- to help me work through conflict in a specific relationship
How many counseling sessions do you anticipate committing to in order accomplish your goal(s) for counseling? (please select one) *

Up to 4 sessions Up to 8 sessions Up to 12 sessions As many sessions as it takes Ongoing
Please click in the box next to items on this list that have affected your quality of life WITHIN THE PAST 7 DAYS. *

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
What led to you choosing Life Training for you counseling at this time? (please select one) *

Google search Our Facebook page Our website Recommended by a friend Recommended by a family member
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. Their intention is to teach me how to live in God's best for my life and relationships. I understand that my counselor is a Licensed/Ordained Christian minister and is Certified/Licensed counselor by the National Christian Counselors Association. My counselor is not a therapist or mental health 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 difference of views 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 standard fee for each session depends upon which counselor I am seeing. If I am meeting with David Ralston, PhD, his fee per session is $110. If am meeting with Ann Ralston, CTC, her fee per session is $100. In the event that I happen to meet with both counselors, I understand that the fee will be $160 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 at no cost to me. I understand this is very important information that will allow my counselor to individualize my care. The APS is an 18-question multiple-choice questionnaire, and is an important diagnostic tool that will provide my counselor an accurate profile of my God-given, inborn characteristics. This will be used by my counselor as baseline information for counseling. My counselor will discuss this in greater detail at one of my first few appointments. I also understand that any APS profiles completed after my initial counseling session (such as children, friends, coworkers, etc.) will be at the cost of $60 per person. (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 nonprofit 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 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 3.74% 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 miss 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 Form

https://lifetrainingcounseling.org/credit-card-authorization-form/
Every client at Life Training is asked to keep credit card information confidentially on file with our office. This card will be billed for each session unless you specifically request to pay at the time of the session with another means of payment. This on-file card will be charged in the unlikely event of a late-cancelled or no-showed appointment. Please click this link above to be taken to the PDF document file. If you are unable to print this form, we will have a copy in our office for you to fill out at your first appointment. *
Initial here to indicate your understanding and agreement with above
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

Goals for Counseling

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 Form

Section 3 Confirmation