TPC Counseling Ministry Intake Form

Form
The Park Ministries Counseling Intake Form
Date *

Month Day Year
Date
Name *

First Name Last Name
Age *
DOB *

Month Day Year
Date
Spouse's Name

First Name Last Name
Age
Spouse's DOB

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Business Phone Number
Please enter a valid phone number.
Employer *
Highest Grade Completed *
Present Church Membership *
Marital Status *

Married Single Separated Divorced Widowed Engaged
Married/Date of Marriage
Separated/Date of Separation
Divorced/Date of Divorce
Number of Previous Marriages
Widowed(Date)
Engaged(Wedding Date)
Children - Names & Ages:
Child 1 Name
Child 1 Age
Child 2 Name
Child 2 Age
Child 3 Name
Child 3 Age
Child 4 Name
Child 4 Age
Child 5 Name
Child 5 Age
Father's Name

First Name Last Name
Father's Age
Mother's Name

First Name Last Name
Mother's Age
How many siblings did you grow up with? *
Have you ever served in the military? *
If yes, when and what branch?
Do you gamble excessively? *
Have you ever received counseling before? *
Date of previous counseling

Month Day Year
Date
Are you under the care of a physician or psychiatrist? *
Are you on Medication?
In case of emergency, who should we notify?
Name
Emergency contact phone number
What is the specific concern that has initiated your request for counseling?
What have you done about your situation up to this point?
What specifically do you expect your counselor to do to help you with this concern?
Today, I am
What I wish I could change is
I sometimes wonder, "What if
I get upset when
Jesus Christ is
I feel uncertain about
If you were to die today, are you certain you would go to heaven?

Yes No Uncertain
WAIVER OF LIABILITY:

THE PARK CHURCH CANNOT BE HELD LIABLE FOR ANY PERCEIVED DAMAGES INCURRED DURING COUNSELING SESSIONS.
Signature *

Clear
Counseling Ministry Purpose Statement: To assist in developing Kingdom citizens by providing Christian counseling and activities which aids counselees in understanding who they are in Christ and applying their faith to life situations so that they may better worship and serve God.
COVENANT OF CONFIDENTIALITY
Counseling sessions are to be kept confidential and should not be disclosed to anyone except in the following circumstances:
1. The counselee appears to be a threat to harm him/herself, any other person, property or there are any reports of abuse to a minor, the elderly, or the handicapped. Such instances must, by law be reported.
2. Supervised sessions with persons within the counseling Ministry or in a class setting for Lay Counselors for instructional purposes.
3. Counseling procedures and progress may be discussed with the minor's parent or guardian for counselees who are minors.
4. When subpoenaed by the court to submit case notes for trial purposes. (Counselors are legally bound to submit the requested chart materials.)
I agree to adhere to the confidentiality covenant as stated above.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Form

The Park Ministries Counseling Intake Form

Children - Names & Ages:

WAIVER OF LIABILITY:

Counseling Ministry Purpose Statement: To assist in developing Kingdom citizens by providing Christian counseling and activities which aids counselees in understanding who they are in Christ and applying their faith to life situations so that they may better worship and serve God.

COVENANT OF CONFIDENTIALITY