Pastoral Counseling Intake Form

Pastoral Counseling Intake Form

Pastor: Curtis B. Nugin Sr. Loving U 4 Life Ministry Per Session: $100
Client Information

First NameLast Name
MaleFemale
Email
example@example.com
Phone Number
Format: (000) 000-0000.
GriefRelationshipPremaritalBoys To Men MentorshipSpiritual Guidance
VirtualPhone
One-timeWeeklyBi-WeeklyAs needed
Reason for Seeking Pastoral Counseling (Please briefly describe what brings you to counseling at this time)
SingleDatingEngagedMarried
Length of relationship (if applicable)
Main concern or goal for cousenlig:
Boys to Men Mentorship (if applicable) Age of participant:
Identity & self-esteemDiscipline & responsibilityCommunication & respectFaith & character developmentLife skills & decision making
YesNo
Very importantSomewhat importantNot important
Goals & Expectations. Please answer the following to help guide our session: What do you hope to gain or receive from this counseling/mentorship session?
What are your expectations of me as your pastor/mentor during this session? (e.g., prayer, guidance, listening, accountability, biblical counsel)
YesNo
Financial Agreement
- I understand that the counseling fee is $100 per session, payable via Cash App $LU4L, due at or before the time of service.
- I understand that missed appointments or late cancellations may require payment unless otherwise discussed.
Payment Method
Signature

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Consent & Acknowledgment

I understand that pastoral counseling is faith‑based guidance and support, not a substitute for licensed mental health therapy or medical care. I voluntarily consent to receive pastoral counseling services from Pastor Curtis B. Nugin Sr., Loving U 4 Life Ministry, and acknowledge that all information shared will be treated with respect and confidentiality within ethical and spiritual guidelines.
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