Staff & Faculty Care Form

Staff & Faculty Care Form | Fieldstone Counseling

Complete the form below to provide some background information for your Fieldstone Counselor
Please answer the following questions honestly and accurately then check that you agree to the terms and conditions at the end. Fieldstone reserves the right to decline your request if your agreement is not given on the last 4 questions.

Staff and faculty care sessions last 50 minutes and are one time appointments. If more time is needed to address the issue, then formal intake paperwork must be submitted through the Fieldstone website to begin ongoing counsleing. Again, this is NOT the form to begin ongoing counseling. Please exit this form and return to the website if more than the one-time session is desired. https://fieldstonecounseling.org/meet-with-a-counselor

Any further questions can be sent to the office at office@fieldstonecounseling.org

Please note the following limitations: Fieldstone Counselors provide biblical counseling. They cannot provide clinical recommendations, medical diagnoses, legal counsel, or family mediation services. We are also not able to begin while active police and/or CPS investigation is taking place.
Name (of person requesting consultation)*

First NameLast Name
Email*
example@example.com
Please list the first and last names of any additional parties who will attend the consultation and their relationship to you: (If you are attending alone write N/A)
Fieldstone values the opportunity to provide counseling to individuals, couples, and families. Fieldstone does not provide mediation services. In family cases where there is more than one family unit involved, each family unit will need an individual consultation with a counselor before a larger, family counseling session can be set up in person. We do not offer these large group sessions in a remote format. Extended family counseling cases in need of mediation services are advised to pursue referrals and resources in their local community.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Age
Individual (1 adult age 18 or older)Marriage/Couple (2 adults)A child or adolescent (1 person age 17 or younger attending the session alone)Family (A group of 2-4 individuals or parents with an adolescent)Church/organizationA work relationship (co-worker/colleague)Other
Green Office, 1559 Corporate Woods Parkway, Suite 10, Uniontown, Ohio 44685Lakewood Office, 14398 Detroit Avenue, Lakewood Ohio 44107RemoteOther
What is the name of the organization or church that you are a part of?
Write N/A if not applicable
Please give a summary of the situation you are seeking a session for (3-4 paragraphs).*
What has been done to address the situation so far?*
What are your goals for the session?*
Please list best available times: (Give at least 3 options. Our operating hours are Monday through Friday between the hours of 9am - 5pm EST.)*
**If your session is part of a school or church counseling program then please contact the administrator of your organization for details regarding session times and locations
Do you have a Fieldstone counselor you would like to request? Any other counselor specifications?
We do our best to accommodate these requests but cannot guarantee that all will be available.
Staff and faculty care sessions last 50 minutes. If further counseling is required, formal intake paperwork must be submitted. Again, this is NOT the form to begin ongoing counseling. Please exit this form and return to the website if more than a one time session is desired. Once your consultation has been scheduled with your counselor please visit the "First Session" page on our website. This page has all of the directions, financial details, and other information to help you have a successful consultation.*

I understand and agreeI disagree
Finance: Consultations have a suggested donation rate of $75 for individuals and $110 for marriage, family, and church-related. For groups of 3 or more please contact us for special rate arrangements. Donations will be processed using an email-based system called Square. This is a secure system that allows us to send an invoice directly to your email. You can expect this email to arrive on the next Wednesday or Friday following your session. Cancellation Policy: If you need to cancel the consultation contact your counselor directly as soon as possible. We ask that you give at least a 24-hour notice for cancellations. If you fail to provide 24-hour notice we would ask you to provide a $50 donation for your missed consultation (unless the cancellation was due to an emergency). Alternatively, your church or organization may be covering the session. Please include that information in the next question.*

I understand and agreeI disagree
Should your church or another third party (other than yourself) be contacted regarding the suggested donation request? If so, please give a name and email address below
Please Note: If there is no response from your Third Party Payer, the invoice for the consultation will be sent to the email address you provided above.
Hold Harmless Agreement: CAUTION—READ CAREFULLY BEFORE SIGNING: In consideration of the offer and provision of biblical counseling, you agree to release, waive, discharge and covenant not to sue Fieldstone Counseling and/or its affiliates, its officers, servants, agents, and employees, including individual counselors, as well as Parkside Church, Parkside Church Green, and/or their affiliates, officers, servants, agents, and employees (hereinafter referred to as “releasees”) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or relating to any loss, damage or injury, that may be sustained by you, or to any property belonging to you, whether caused by the negligence of the releasees or otherwise relating to your participation in biblical counseling with Fieldstone Counseling. You further agree to indemnify and hold harmless the releasees, from any loss, liability, damage, or costs they may incur due to your participation in biblical counseling with Fieldstone Counseling, whether caused by the negligence of any or all of the releasees, or otherwise. By signing below, you agree that it is your express intent that this Release shall bind the members of your family and spouse, and your heirs, assigns, and personal representatives. In signing below, you acknowledge and represent that: A. You have read the foregoing Informed Consent and Hold Harmless Agreement and sign it voluntarily; B. You are at least eighteen (18) years of age and fully competent; and C. You execute this Informed Consent and Hold Harmless Agreement for adequate and complete consideration, fully intending to be bound by same.*

I understand and agreeI disagree
What you should expect next: After submission, we will begin working to pair your session with one of our counselors. This process can take up to 2 weeks. Please allow additional time if paperwork is submitted during weekends or national holidays. Once we have paired you with a Fieldstone Counselor you will be contacted by them directly to schedule your consultation. We take all information provided on the intake paperwork into consideration, including your availability and selected location. In light of this, there is a possibility that your chosen location and time frame may be at maximum capacity with our current counselors. If this is the case, then you will be notified and placed on a waitlist until a counselor becomes available. **If your session is part of a school or church counseling program then please contact the administrator of your organization for details regarding session times and locations.*

I understand and agreeI disagree
Should be Empty:

Staff & Faculty Care Form | Fieldstone Counseling