Clinical Counseling - Client Intake Packet
Dr. Felicia McClinton,
Clinical Counselor
Client Information
Full Name:
Preferred Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Pronouns:
Address:
City/State/Zip:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Preferred Method of Contact:
Phone
Email
Text
Emergency Contact Name & Relationship:
Emergency Contact Phone:
Format: (000) 000-0000.
Spiritual & Faith Background (Optional)
This section is central to ministry-based counseling.
Faith or Spiritual Affiliation:
Church / Ministry Affiliation (if applicable):
How would you describe your current relationship with God / spirituality?
Would you like prayer, scripture, or spiritual practices included in sessions?
Yes
No
Occasionally
Unsure
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Reason for Seeking Counseling
What brings you to counseling at this time?
How long have you been experiencing these concerns?
What are your hopes or goals for counseling?
Previous Counseling
Have you received counseling?
Yes
No
If yes, please describe:
Are you currently receiving mental health counseling or psychiatric care elsewhere?
Yes
No
Emotional, Mental & Physical Well-Being
Are you currently experiencing any of the following? (Check all that apply)
Anxiety
Depression
Grief
Trauma
Marital/Family Conflict
Spiritual Distress
Other
Are you currently taking any medications that affect mood or functioning?
Yes
No
If yes (optional):
Do you have any significant medical conditions that may affect sessions?
Yes
No
If yes (optional):
Safety & Crisis Awareness
Have you experienced thoughts of harming yourself?
Yes
No
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Have you experienced thoughts of harming others?
Yes
No
If yes, please explain briefly:
If you are in immediate danger, emergency services will be contacted to ensure safety.
Substance Use (Optional)
Do you currently use alcohol or substances that concern you?
Yes
No
If yes (optional):
Informed Consent for Counseling
I understand that
Christian Clinical Counseling
is a ministry-based service that integrates emotional support and spiritual guidance grounded in faith. I understand that this counseling is not medical, psychiatric, or psychological treatment and is not a substitute for emergency services. I understand the limits of confidentiality, which include but are not limited to: risk of harm to self or others, abuse or neglect of a minor, elderly, or vulnerable person, or legal requirement. I understand that referrals may be made to licensed professionals when concerns extend beyond the scope of our areas of clinical counseling. I understand that participation is voluntary and that I may discontinue services at any time.
Client Signature:
Date:
-
Month
-
Day
Year
Date
Tele-Ministry Consent (If Applicable)
I understand the benefits and limitations of receiving counseling through phone or video platforms. I consent to receive counseling services via tele-ministry.
Client Signature:
Date:
-
Month
-
Day
Year
Date
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Counselor Information
Clinical Counselor: Dr. Felicia McClinton, DCCC
Title: Counselor
Ministry / Church Name:
Contact Information:
This intake form is for ministry-based counseling purposes and will be maintained in accordance with ethics and confidentiality standards.
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