Grace Forward Affordable Therapy Program Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Email Address* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
City & State
5
Pregnancy/Postpartum Status
Pregnant
Postpartum
Neither
6
What challenges are you facing?
Postpartum depression
Anxiety
Identity loss
Burnout
Lack of support
Spiritual disconnection
7
Briefly describe what you’re going through
8
What are you hoping to gain from this program?
9
Are you currently seeing a licensed therapist?
Yes
No
10
On a scale of 1–5, how ready do you feel to participate?
1
2
3
4
5
Not ready
Very ready
11
Grace Forward provides faith-based coaching and emotional support and is not a substitute for licensed medical or mental health treatment. Participation is voluntary, and confidentiality is respected except in cases of harm to self/others or legal requirements.

completing this form does not constitute mental health counseling, if you are in crisis please contact 911 or call or text 988
12
I have read and agree to the Informed Consent.* This field is required.
I have read and agree to the Informed Consent
13
Type your full name as electronic signature* This field is required.
14
Date* This field is required.
Date
Month
Day
Year
15
This program may include both faith-based coaching and services provided by licensed professionals. Licensed professionals operate independently and provide clinical care under their own scope. Grace Forward provides program structure, support, and faith-based guidance but does not direct clinical treatment.

I understand that services provided by Grace Forward Foundation are faith-based and supportive in nature and do not constitute medical care, mental health therapy, counseling, or licensed clinical treatment. Grace Forward Foundation does not diagnose, treat, or cure medical or mental health conditions.

Personal Responsibility

I acknowledge that I am responsible for my own physical, emotional, and spiritual well-being during participation. I agree to seek professional medical or mental health care when needed.

Release of Liability

To the fullest extent permitted by Alabama law, I release and hold harmless Grace Forward Foundation, its directors, officers, employees, volunteers, and representatives from any claims, liabilities, or damages arising from my participation, except in cases of gross negligence or willful misconduct.
16
Use of Information

Confidential information will be used solely for nonprofit program purposes and will not be shared with unauthorized individuals or entities.

Limits of Confidentiality

I understand that confidentiality may be broken if:

    •    Disclosure is required by Alabama or federal law

    •    There is a reasonable belief of harm to self or others

    •    There is suspected abuse or neglect of a child, elderly person, or vulnerable adult

    •    Written consent is provided by the participant

Group Program Acknowledgment

For group-based programs, I agree to respect the privacy of others and not disclose personal information shared by fellow participants outside of the program.
17
Group confidentiality expectations (not legally guaranteed)
Communication boundaries (no 24/7 support)
Crisis disclaimer (not emergency services; contact 988 or 911 if needed)
Faith-based participation is voluntary
18
I have read and agree to the Program Addendum.* This field is required.
I have read and agree to the Program Addendum
19
E-signature (draw or type your name)* This field is required.
20
Date* This field is required.
Date
Month
Day
Year
21
I confirm that I have read, understood, and agreed to all required documents, including the Informed Consent and Program Addendum.* This field is required.
I confirm that I have read, understood, and agreed to all required documents, including the Informed Consent and Program Addendum.
22
Signature
Should be Empty: