Client Intake Form

Full Name:

Gender:

Birthdate:

Date

Current Age:

Preferred Phone Number:

Email:

example@example.com

Mailing Address:

Emergency Contact Name:

Emergency Contact number:

Relationship to you:

Emergency Contact email:

example@example.com

How did you hear about us?

Below please find important information outlining the type of counseling we provide as well as some important policies. Please carefully read the information below and initial each segment to confirm your understanding. Your full signature at the end of this document confirms that you understand and agree to the information in this document.

We are not state licensed LPC's. Biblical Counselors receive credentialing through various faith-based governing organizations. The organization to whom we are accountable for continuing education, ethical and Biblical counseling practices is the Association of Biblical Counselors.

All information you share will be strictly confidential, except that which is mandated as reportable by law, or that which you consent to have shared. We have an obligation to report any activity we have substantial reason to believe may lead to harm to the client or to another, but will make every effort to resolve the situation without breaking confidentiality.

As regards minor children, specifics shared by the child with the counselor will remain confidential, but parents will be kept informed of any helpful insights which may assist the parents in their care of the child.

While we will be praying for you outside of our meeting times and are expectant of positive results from the counseling process, we cannot guarantee any particular outcome. Active participation of all involved parties, including honesty and completion of any suggested homework assignments, will greatly assist in the success of the process.

Do not fear judgment as you share your struggles. As represntatives of Jesus, our job is to listen and help, not to judge. James 5:16 says "Confess your sins one to another so that you may be healed." Our time together is a safe place for confession.

There are times the counseling process may be emotionally stressful and individuals may be challenged to move outside their comfort zone. Sometimes a counselee may even feel worse for a time as difficult situations are brought into light. It's important to know this is to be expected and is a normal part of the process, like the pain of a physician cleaning out a wound before it can properly heal.

We may make recommendations regarding how often and for how long we should meet based on your situation, but ultimately that is always your decision. Counseling is a process that cannot be forced.

By signing below, you acknowledge that you understand these aspects of the counseling process, and release the counselor from liability should your counseling not lead to the results that you desire.

1. The Counselor is commitment to providing excellent care with a commitment to the highest level of integrity and professionalism.

2. The Counselor reserves the right to discontinue counseling services at any time for any reason. Counselee will be notified in writing of any such decision.

3. The Counselee has the right to discontinue counseling services at any time, for any reason. Written notification is requested, but counselee is not obligated to explain their reasoning.

Signature (use finger or mouse to sign)

Please respond to the following questions to the best of your ability. This will help guide the counselor in their understanding of your life and circumstances so they can provide you with the best possible care. Please answer every question – you may respond “I don’t know” or “N/A” if necessary.

Current Occupation

Marital Status

If single, have you been married before?

If married, does your spouse know you are coming for counseling? Please list spouse name, length of marriage, and how you would describe the marriage currently. (i.e. stressed, struggling, healthy, etc.)

Do you have children? If yes please list names and ages.

Any major changes in relationships lately? (i.e. death, breakup/divorce, stress or loss, etc.)

Do you believe in God? If yes, please fill out the other questions in this section.

Do you consider yourself a Christian? If yes, please briefly describe what your relationship with God is currently like (i.e. questioning, struggling, growing, strong, etc.)

Do you currently attend church? If so, describe your involvement. (i.e. sometimes attend, regularly attend, actively involved, etc.)

Please list any prescription medications, over the counter medications, or vitamin supplements which you take on a regular basis.

Describe your current sleep habits.

Any recent changes in mood, personality, memory/concentration, work or study habits?

Describe any significant medical issues you are currently having:

Describe any struggles with addictive substances or behaviors, disordered eating, self-harming behaviors, or any other factors that may be affecting physical and mental health.

What is the main reason you are seeking counseling?

When did the problem begin?

Is any significant event or trauma invovled?

What have you done so far to try to address this problem?

How do you hope counseling will help?

Is there anything else you would like me to know about you or your history as we begin counseling?

COUNSELEE GENERAL INFORMATION

CONSENT AND RELEASE OF LIABILITY

QUALITY OF CARE AND RIGHT TO DISCONTINUE COUNSELING

PERSONAL DATA AND BRIEF LIFE HISTORY

RELIGIOUS BACKGROUND/PREFERENCES

CURRENT HEALTH

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