Complete Your Intake Form

Todays Date

Date

Client Name

Age

Birth Date

Date

Spouse/Parent Name

Birth Date

Date

Address

Phone Number

Email

example@example.com

May I contact you if necessary about appointments, etc. by email?

Your employer

School (if adolescent)

Marital Status

Married: How long?

Separated: How long?

Divorced: How long?

Widow/Widower: How long?

Married: Times Married?

Names & Ages of Children

Living With You?

YesNo

Who referred you to me

May I send a thank you to your referrer

Referrers Address

Name/Address of nearest relative NOT living with you:

Name

Phone

Address

Primary Doctor

Phone Number

Date of last examination by your physician

Date

List any major health problems or concerns you have and for which you currently receive treatment

List of medications you are currently taking

Any Problems with:

EatingSleepingChronic PainRecent Weight Changes

Please describe any answers checked above

Have you or a family member ever received psychiatric or psychological help or counseling before, including any prior hospitalizations for mental or emotional illness? If yes, please explain: (when, where, with whom, and why)

Briefly describe your reason for seeking counseling:

What is your most difficult relationship right now?

What is your most difficult emotion right now?

LCCS operates on a cash basis (cash, check, credit card) with client paying for services after each session.

I do not accept any insurance. The large majority of pastoral counseling services are not covered by insurances, and I strive to keep counseling services affordable.

Sessions are $75 per 50-minute, individual sessions. Two-person (family) sessions are $80. Any time over 50 minutes can be prorated.

I respectfully ask for a 24-hour notice of cancellation. If I do not receive a 24-hour notice, I reserve the right to charge for the missed session.

The needed profile assessment I run at our first session is a vital part of treatment and is rendered at a cost to you of $60 per profile.

If necessary, in urgent situations, calls up to ten minutes in length may be made to me outside of work hours at no charge. Extended calls are prorated.

Thank you for taking the time to complete this information.

Thank you for your trust. I am here to help you in any way I can.

I have read, understand, and agree to comply with the policies of LCCS and am consenting to engaging in Christian counseling. I understand that I am responsible for any decisions I make regarding my life.

Signed

Date

Intake Form

Policies Review and Acknowledgement