Initial Intake Form
Please fill this form out as completely as possible. (Placement with a counselor may take up to 4 - 6 weeks)
Full Name:
*
First Name
Last Name
Gender:
*
Please Select
Male
Female
Age:
*
Martial Status:
*
Please Select
Single
Married
Divorced
Widowed
Seperated
Minor Child
Spouse's Name (if applicable):
Seeking:
*
Individual Counseling
Couples Counseling
Family Counseling
Counseling for a minor (17 & under)
Referred By: (Pastor, church, family member, friend, etc..)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do you want to receive appointment reminders and assignments through text?
*
Please Select
Yes
No
Can we leave a message when we call you?
*
Please Select
Yes
No
Briefly describe reason(s) for counseling:
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Have you met with a CLM counselor in the past? If so, who?:
What do you hope to accomplish in counseling?:
*
Financial Pledge:
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CLM is a pledge-based ministry. We do not have a set fee for counseling because we do not want finances to be the reason you do not seek biblical counseling. To help you determine what you want to contribute, please consider the following information: Typical pledge is $50-$75 per session. Pledging $120 per counseling hour would cover all expenses to run as a ministry. However, because not all clients can afford this amount we ask you to pledge an amount appropriate for you. The amount of money you pledge goes directly to the counselor spending time with you. Any amount contributed over $50.00 per 1-hour session is considered a tax-deductible donation. (Example: Pledge $75 and $50 will go toward the service of counseling. The remaining $25 will be reflected on a Charitable Donation Receipt mailed at the end of the year.) Contributions may be made via cash, check, debit or credit at the time of your counseling. The cost for any assigned material such as books, CD’s, or online downloads will be in addition to your pledge and yours to keep. Insurance Filing: Most insurance companies do not reimburse for biblical counseling services. If your insurance company does cover this service we ask that you do your own filing. We can provide any requested information.
Client Agreement:
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The best counseling experience happens when both client and counselor work together. We commit to offering honest, spiritual direction as well as prayerful consideration of applicable scripture as it pertains to your life. We ask that you commit to the following: 1. Honesty & humility throughout the counseling process. 2. Keeping your counseling appointments, unless urgent matters interfere, in which case we would request that you notify us as soon as possible. 3. Completing your homework assignments. 4. The Word of God, the Bible, will be the highest source of authority. 5. At the conclusion of the counseling process, a Release Session will be scheduled to discuss any recommended assignments to encourage continued growth and health.
Confidentiality & Release of Information:
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I have voluntarily sought counseling at Christian Life Ministries. I am under no obligation or compulsion to accept this counseling or any advice I may receive during this counseling process. I further agree to hold Christian Life Ministries and its staff free from any and all liability, loss or damage of any kind that may arise as the result of the counseling. I understand that Christian Life Ministries and any employee or other representative of CLM is offering this counseling voluntarily, at a voluntarily pledged cost, and that I or CLM can terminate or limit this counseling at any time. I understand that this counseling is not a medical or psychiatric service, but is exclusively the sharing and explaining of principles set forth in the Bible as applied to my personal situation. I understand that any counselor representing Christian Life Ministries might thoughtfully choose to, or may be legally bound to disclose information received from me in the following circumstances: The information may be disclosed to my spouse, if the counselor believes that this may strengthen the marriage relationship or correct a misunderstanding in the mind of my spouse. The information may be disclosed to law enforcement officers or other governmental officials, if the counselor believes that the information may be about an actual, threatened or potential crime, other violation of law, or other matter within the responsibilities of the officers or officials to whom the disclosure is made. The information may be disclosed to whomever the counselor feels should have it, if the counselor believes it is about an actual, threatened or potential suicide, or other act of self- harm. The information that minors disclose regarding abuse, illegal activities, social dangers or abortion may be disclosed to parents or other appropriate authorities if the counselor believes such disclosures will enhance the counseling process or provide necessary protection for the minor. The information may be disclosed to other counselors representing CLM, as part of the normal assistance that the counselors give to each other in their work. *This document will be reviewed and signed by both client & counselor during initial session I have read, understand, and agree to all of the above statements.
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