Care and Counseling Intake Form

Full Name*

First NameMiddle NameLast Name

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

E-mail*

example@example.com

Phone Number*

This is my:*

Are you a Member of Patria Church and have you attended regularly in the past six months?*

Please answer below

I have completed Growth Track and I am a Member of Patria. I have not completed Growth Track*

Have you completed or plan to complete Growth Track in the next six months? Yes/No I have not completed Growth Track and I attend a different church.

Which campus do you attend?*

RanchoPomonaAlamedaCorona

What is your current relationship status?

MarriedSingleEngagedDivorced

Who are you requesting counseling services for today?

SelfCoupleChild Under 18 years of ageFamily

Have you ever been diagnosed with any mental health challenges?*

What was the diagnosis?

Have you ever thought about, or attempted suicide?*

YesNo

If so, are you currently seeing any type of counselor or therapist?*

YesNo

Have you received counseling from a Patria Pastor or Counselor previously?*

YesNo

If yes, with whom? Date (s)*

Area(s) of Concern Please select as many as apply:

Please provide any additional information regarding the reason for your request for counseling.*

PLEASE READ CAREFULLY AND SIGN

Client Agreement:

1. Pastoral Counseling Policy

Sound biblical counsel and compassionate shepherd care are some of the blessings God has given his people in the person of pastors and teachers. We thank God with you that these resources are available as part of the Pastoral Counseling Ministry (“PCM”) of Patria Church.

The pastoral counsel you may receive is for Patria Church Members Only and provided free of charge, except for occasional nominal costs of materials, or as described below, as an outreach ministry of Patria Church. The PCM is intended to provide you with sound biblical instruction and application to the issues of life. The PCM is not intended to be a substitute for professional mental health care, medical care or legal counsel, as the pastor you speak with has not received specialized training in medicine, psychology, psychiatry, or law.

2. Disclosure of Information

Patria will not disclose any information discovered as part of the PCM, except under the following circumstances:

You consent to such disclosure in writing or life or safety of persons or property is threatened. Patria will contact the proper authorities to report any information it has relating to threats to the life or safety of persons or property, including but not limited to the following circumstances:

Child abuse; elder abuse dependent adult abuse threat of self-inflicted harm information which poses a threat to the Patria staff, PCM staff or the Patria congregation and any other disclosure required by law.

3. Voluntary Participation & Assumption of Risk

I acknowledge that I (or my child, as applicable) am voluntarily participating in the PCM at Patria Church. I hereby agree to accept any and all risks incidental to my (or my child’s) participation, including but not limited to any nominal financial fees and costs. Further, I acknowledge that I have not relied on any representations from Patria, its agents or representatives, as to such risks or costs.

4. Release

I acknowledge that I am executing this release in consideration for being permitted (or my child being permitted) to participate in the PCM, and that Patria would not allow me (or my child) to participate in the PCM without the execution of this release.

I fully understand and I am accepting the risks associated with the PCM and with my (or my child's) participation in the PCM, and I hereby release any and all claims, demands, and causes of action of whatever kind and character, which I may have (or my child may have) now or in the future against Patria, its agents, officers, directors, volunteers, employees, and representatives arising out of or in any way related to such participation in the PCM, the actions of any counseling party, volunteer of the PCM, or the actions (or inactions) of any other participant of the PCM.

Furthermore, I hereby agree, on behalf of myself and on behalf of any person or entity claiming by, through, or under me, to defend, indemnify and hold harmless Patria and its agents, officers, directors, volunteers, employees, or representatives agents and employees, from any and all claims, demands, and causes of action of whatever kind and character which may ever be brought against Patria or its agents, officers, directors, volunteers, employees, or representatives, whether such claims are known or unknown, at law or in equity, arising out of or in any way related to my participation in the PCM, my actions (whether such actions occurred inside or outside of the PCM, including but not limited to acts committed against my spouse, family members or any other person), the actions of any counseling party or volunteer of PCM, or the actions (or inactions) of any other participant of the PCM.

5. Christian Mediation and Arbitration

As further consideration for being allowed to participate in PCM, I agree that, with respect to any dispute that may arise out of the counseling relationship between me (or my child) and Patria (or any of Patria’s officers, directors, employees, agents, or volunteers), such disputes shall be resolved through mediation and arbitration to be conducted by a mutually agreed upon Christian mediator. In the event that mediation is not successful, the parties agree to resolve any claims or disputes by Christian arbitration and to waive any right to pursue any action in court. Such arbitration ruling shall be final and binding. I further agree that the costs of any such mediation and arbitration shall be equally divided between Patria Church and me.

6. Additional Information

Prior to acceptance into the PCM, please complete the questionnaire attached hereto as Exhibit “A” with respect to the party seeking counseling.

7. Knowing and Voluntary Execution

I acknowledge that I have carefully read this document completely and fully understand its contents. I am aware that this document shall serve as both a consent to participate in the PCM and a release of liability. Further, I acknowledge that I have executed this document of my own free will. In addition, I authorize the release of information in accordance with Patria Church policies. I further give permission for my child, to participate in the PCM under the same terms specified herein.

By my electronic signature below, I agree to the massage policy and client agreement above.

Date

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Care and Counseling Intake Form

Intake Information