Intake form for Unlockinghearts

UNLOCKINGHEARTS,LLC

Intake Client Form
Unlockinghearts, LLC

My name is Elizabeth Bowman. I am the founder and principle operator of Unlockinghearts, LLC. I have had the privilege to mentor, disciple, biblicallly counsel and journey alongside many women from a wide range of backgrounds, including those who have suffered through abortion, substance abuse, and various other forms of physical and emotional trauma. I come along side individuals to help them identify and live out the truth of their identity in Christ Jesus. I offer discipleship counseling which is gospel centered, coming alongside you as an individual with words of truth to encourage, teach, comfort and assist you during your time of need. The primarily focus is to deliver both grace and truth to help you build a solid foundation of understanding, receiving and living out your identity in Christ. Through prayer and the Word of God, I will help you come to a greater understanding of your identtity in Jesus. The hope is that even if your circumstances do not change-you are transformed and can begin to experience Jesus in the midst of your everyday struggles in life. Please undersatnd that I am not a licensed professional counselor. Elizabeth is commissioned as a Minister by Network 220.

( www.network220.org) a network of ministers that biblical counsel with explicit goal of helping people live an abundant life in Christ.

Romans 12:2 "Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is acceptable and perfect."

CLIENT AGREEMENT

Thank you for your interest in working with me as a client. Please read this information carefully and ask

any questions you may have before signing this agreement.

Phone calls ( 704-604-9363): Calls are returned Monday through Friday, all calls will be returned within 1 business day.

Please leave your phone number and first name with your message.

Emergencies: If you have an emergency please call 911 or go to your nearest Hospital Emergency Room.

If you feel I need to be made aware of the situation please call me after seeking appropriate emergency care.

Cancellation policy: Unlockinghearts has a 24 hour cancellation policy. If you fail to cancel a scheduled appointment, I cannot use this time for another client. Please be aware any outstanding cancellation fees must be paid before scheduling another appointment.

Therefore, you will be billed for the entire cost of a missed appointment.

Please complete this form with as much detail as you can and submit prior to your session. Your information is important to me and will be held in the upmost confidence.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Where may I contact you*
Emergency Contact Person*
Emergency Contact cell phone *
Current martial status*
Are you currently employed?*
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
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Date of Birth*

MonthDayYear
Age*
Have you ever attempted suicide? If yes, please explain
Do you currently have thoughts of suicide?*
If yes, do you have a plan?*
How are you sleeping? (How many hours, quality etc.)*
Have you ever had an abortion? *
If yes, how many?*
Please read the list and check any that you are currently feeling or have felt over the last 3 months*

CriticisedOverwhelmedApprehensiveUncertaintyAgitatedParanoidIntolerantMuddledGuiltyOverworkedAggravatedParalysedDepressedRejectedEasily IrritatedPersecutedHelplessAnxiousHopelessUneasySadDepressedGrievingAbusedFearfulUnable to GrieveDistressImpatientAngryWorriedOutragedSleeplessNervousRestlessIntimidatedNONE
Please highlight ALL the current experiences spiritual and emotional you are having:*
If you have experienced other major trauma, please briefly describe below:*
Are you taking any prescription drugs? If so, please list*

Please take a moment to consider the following.*

	Zero	Minimal	Moderate	High
My family stress is
My relationship stress is
My work stress is
My financial stress is
My health stress is

Please take a moment to consider how much time you have for each of the following.*

	Zero	Minimal	Moderate	High
'ME'
Exercise
Relationship (s)
Meditation
Social

Would you like to go on my mailing list. No spam! Just updates and inetrests.*

YesNo
How did you hear about me*
Identify any habits or behaviors that you would like to change:*
State in your words what you consider to be the nature of your main problem(s):*
Please describe when and how you believe your problems began:*
What do you expect Unlockingheartst to do for you?*
Please list three goals you have for self-improvement *
Please list three major strenghts/gifts that you have*
I have reviewed this Intake Informed Consent Agreement. I likewise understand my Client's Rights set in this form.

I accept this agreement and consent to biblical counseling and discipleship

By signing this Client Information and Confidentiality, Disclosure, and Consent Form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive services for me, and I understand that I may stop such services at any time.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Elizabeth Bowman and Unlockinghearts, LLC from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).
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Signature

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Date*

MonthDayYear
Date

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UNLOCKINGHEARTS,LLC