Counseling Client Intake Form

Counseling Client Intake Form
SECTION 1: CLIENT INFORMATION
Client's demographic (please select one)*

Adult (18 > years of age)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*

MonthDay Year
Client's age *
Client's mobile number*
Parent / Guardian's mobile number (if client is under 18 years of age)*
Client's home address*

Street Address

Street Address Line 2

City State

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

SingleSeparatedDivorcedWidowedDatingLiving togetherEngagedMarried
What is your spouse's name?*
How long have the two of you been married? *
Have you ever been married previously?*

NoYes
How many times have you previously been married?*
What is your partner's name?*
How long have you and your partner been together? *
Do you have any children?*

NoYes
Please provide the name and age of each child*
Spirit, Soul, & Body

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)*

GoodFairPoor
I believe my emotional health is (please select one)*

GoodFairPoor
I believe my physical health is (please select one)*

GoodFairPoor
My current financial status is (please select one)*

GoodFairPoor
If you identity as a Christian, which denomination best describes you? (please select one)*

CatholicOrthodoxAnglicanProtestantPresbyterianBaptistSouthern BaptistLutheranMethodistPentecostalNon-denominationalNot a ChristianOther
Do you currently attend a church?*

NoYes
What is the name of that church?*
How often do you attend that church? (please select one)*

RegularlyOccasionallyRarelyChristmas and Easter onlyNever
Which option BEST describes the primary nature of your relationship with God? (please select ONLY ONE)*

I believe in GodI was baptized as an infantI accepted Jesus when I was a childI think many Christians are hypocritesI think I'm a pretty good personI try hard to become a better personI am an agnosticI think I'm too bad of a person for God to ever love and forgiveI claim God's promises for my lifeI am a fully committed follower of JesusI consider myself to be an atheistI am saved by faith alone in Christ alone
Which option BEST describes your prayer life? (please select ONLY ONE)*

I never prayI ask God to act on my behalfI ask God to help with a crisis or a situation that is outside of my controlI thank God for thingsI pray for people other than myselfI pray that God will change something in meI ask God to forgive me for somethingI praise and worship God
Family of Origin
What is/was your father's name?*
Is he still living?*

NoYes
Is/was he your birth father?*

NoYes
What is/was his occupation during your childhood?*
What is/was your mother's name?*
Is she still living?*

NoYes
Is/was she your birth mother?*

NoYes
What is/was her occupation during your childhood?*
Did (or are) both of your birth parents raise (or raising) you in the same home?*

NoYes
What caused your parents to not be together through part of your childhood? (please select one)*

DivorceSeparationDeathOther
Do you have any step-parents?*

NoYes
How many siblings lived (or live) in your childhood home? *
What position were (or are) you in birth order of your siblings (i.e. 2/4)?*
How old were you when you left home and began living on your own?*
Goals for Counseling
What issues have led you to seek counseling at this time?*
What is your primary goal for counseling?*
How would you describe the intensity of your current situation? (please select one)*

I need perspective to help me deal with a small life issueI need direction to get me back on the right path in my lifeI need counseling to help me move through an intense personal crisisI need guidance to lead me on a journey of soul healingI need Biblical wisdom to help my marriage be saved
How many counseling sessions do you anticipate in order accomplish your goal(s) for counseling? (please select one)*

Up to 4 sessionsUp to 8 sessionsUp to 12 sessionsAs many sessions as it takesLong-term
Please click in the box next to items on this list that have affected your quality of life WITHIN THE PAST 7 DAYS (click all that apply)*

GriefDepressionMarriage problemsIssues with childrenHomelessnessBitternessAnxietyIssues with parentsCompulsivenessSexual ConcernsAdulteryImpotence / EDNervousnessFearHomosexualitySelf-doubtFinancial stressSuicidal thoughtsGuiltAnger with GodLoss of temperSuicide attemptCrying spellsLoss of self-respectMoodinessWeight concernsLonelinessLoss of meaningExcessive worryExcessive stressExcessive fearLow self-esteemDrug useDrug abuseDrug addictionAlcoholismCigarette useSmokeless tobacco useSelf-harm / cuttingUnforgivenessAbandonmentRejectionCodependencyLegal issuesSexually abusedEmotionally abusedPhysically abusedSpiritually abusedOCDPornographyHopelessnessHatredNone of the above
How did you learn about Life Training Christian Counseling? (please select one)*

Google searchOur websiteRecommended by a friendRecommended by a family memberOther
SECTION 1 - CONFIRM
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 - CONFIRM
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
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 meet with both counselors together, 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 Missed Appointments
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
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 missed appointment. Please click the yellow 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 - CONFIRM
By typing my name here, I am confirming that I have read, agreed to, and initialed the information in each part of the FINANCIAL AGREEMENT section above. (If client is under 18 years of age, parent or guardian should type their NAME here)

First Name Last Name
Should be Empty:

Counseling Client Intake Form

SECTION 1: CLIENT INFORMATION

Spirit, Soul, & Body

Family of Origin

Goals for Counseling

SECTION 1 - CONFIRM

SECTION 2: CLIENT AGREEMENT

Counselor Credentials

Client Confidentiality

Client Participation

SECTION 2 - CONFIRM

SECTION 3: FINANCIAL AGREEMENT

Session Fees

APS Temperament Profile

Cash-Pay Only

Payment Methods

Late Cancellations and Missed Appointments

Returned Check NSF Fee

Credit Card Authorization Form

SECTION 3 - CONFIRM