CLIENT INTAKE FORM

Client Intake Form
SECTION 1: CLIENT INFORMATION

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

Adult Individual (even if in a relationship, but seeking counseling alone) Adult Couple (both parties need to complete a separate form if both are clients) 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 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 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
Confirmation
By typing my name here, I am confirming that the personal information I have provided in this CLIENT INFORMATION section 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
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 be only $60. This session will serve as an informal interview -- like a test drive -- to allow both the counselor and the client to decide if the relationship feels right to them. Although it is the desire of Life Training that every client will 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 if I choose to continue counseling after the initial interview, the fee for each session will be a 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
VERY IMPORTANT -- After reading each statement, please check the box to the left of each statement to indicate that you understand and agree with the details of Life Training's credit card authorization agreement. *

Upon submission of the online CLIENT INTAKE form, I will automatically be redirected online to the Credit Card Authorization form in printable PDF format. It is my prerogative to print it off, complete and sign it, and bring it with me to my initial counseling appointment. If I prefer not to print the form on my own, I will be provided with a paper version of the Credit Card Authorization form upon my arrival for my initial counseling appointment. I will be required to complete and sign this form prior to being seen for counseling. All information provided on the Credit Card Authorization form will be kept strictly confidential and will be securely stored in your clinical file. Life Training Christian Counseling does not ask for this information in an electronic format in order to keep each client's important financial information protected as much as possible. The paper document that I complete and sign will serve as my expressed written permission for Life Training Christian Counseling to charge my credit/debit card the agreed-upon fee for all scheduled appointments, missed appointments, late-cancelled appointments, or any unpaid balances on my account. Cash or check are also welcomed as methods of payment for my appointments. However, if full payment is not received by cash or check at the beginning of my appointment, the credit card information kept on file will be billed as per my agreement.
By typing my name in these spaces, I am confirming that I fully understand and agree with each statement of this Credit Card Authorization above (If client is under 18 years of age, parent or guardian should type their name here). *

First Name Last Name
CLIENT SIGNATURE

If client is under 18 years of age, parent or guardian please sign
By signing below, I am stating that: 1) I have thoroughly read all of the information in all three sections of this CLIENT INTAKE form, 2) I understand the content of each section, 3) I am in agreement with the content of each section, 4) I have entered my initials or name, as requested, to confirm my understanding and agreement, and 5) I am committed to all that is being asked of me in this agreement with my counselor, as well as Life Training Christian Counseling. (Please use mouse to sign) (If client is under 18 years of age, parent or guardian should sign their name here)

Clear
Date signed

Month Day Year
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Client Intake Form

SECTION 1: CLIENT INFORMATION

Body, Spirit, & Soul

Family of Origin

Current Issues & Concerns

Confirmation

SECTION 2: CLIENT AGREEMENT

Counselor Credentials

Client Confidentiality

Client Participation

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

CLIENT SIGNATURE