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Home
About Us
Our Services
Fees And Scheduling
Forms
Contact

Home
About Us
Our Services
Fees And Scheduling
Forms
Contact

Home
About Us
Our Services
Fees And Scheduling
Forms
Contact

Home
About Us
Our Services
Fees And Scheduling
Forms
Contact

Home
About Us
Our Services
Fees And Scheduling
Forms
Contact

Release of Liability for
Counseling Services Form

To ensure we have the proper consent for services, please download and complete the required Release of Liability Form.

Please bring signed copy to the office or email it to [email protected]. Otherwise a copy is available to sign at your first appointment.

Download the Form

Intake Form

Before beginning your counseling journey, please fill out the required Intake Form. This helps us understand your current situation and tailor our support to your specific needs. We ask that you provide detailed information to ensure we can provide the best care possible.

Fill Out Below Intake Form

Personal Information

Date

MM slash DD slash YYYY

Name

Birth Date

MM slash DD slash YYYY

Cell Phone

Daytime

Address

Street Address City/State Zip

Occupation

Sex

Marital Status

If married how long?

Spouse’s Name

Divorced how long:

Children (if single, list parents, brothers, sisters)

Age

Sex

Presenting Problem: (Please X all that apply)

Marital issues

Health issues

Job issues

Financial issues

Social issues

Parent/child issues

Issues in past (guilt, family of origin, abuse, etc.)

Other

Symptoms: (Please X all that apply)

Change in sleep patterns/appetite

Hopeless thoughts

Fear/Anxiety

Confusion

Decreased motivation/energy

Suicidal feelings/thoughts

Hallucinations

Mild depression

Severe depression

Suicidal/Homicidal Ideation: (thoughts)

Have you ever attempted to commit suicide or homicide?

Yes

If yes, how?

Is there a history of suicide in your nuclear or extended family

Yes

Are you presently having thoughts of harming yourself or others?

Yes

Have you, or any family member, been involved in the occult?

Yes

What recent event has prompted you to seek counseling?

Describe any additional problems you are experiencing and when they developed.

Please X any losses you have experienced in the past 2 years:

Death of family member/friend

Health

Job

Home/lifestyle

Religious issues: Please briefly describe your relationship with God.

Past Psychiatric History

List previous counselor/psychiatrist:

Place

Length:

1-2 Year (s)

Several Year (s)

Medical Information

How would you describe your current health?

Excellent

Good

Fair

Poore

List any medications you are currently taking:

Has it been more than one year since your last physical or blood test?

Yes

List any previous health problems:

Have you ever abused substances? (alcohol, caffeine, tobacco, drugs)

Yes

Describe your usage of any of the following over the past year:

Alcohol

Caffeine

Tobacco

Drugs (Rx / OTHER)

Marijuana/K2

Psilocybin(mushrooms)

Nutrition/Sleep Patterns

Have your eating habits changed recently?

Yes

If yes, how?

Do you ever self-induce vomiting?

Yes

Binge/eat out of control?

Yes

Have your sleep patterns changed recently?

Yes

If yes, how?

Legal History

Have you been convicted of a felony?

Yes

Of other charges?

Yes

If yes, please describe

Support System

Please X all whom you consider to be a support for you (i.e. with whom would you speak concerning personal problems)

Parent

Sibling

Other relative

Good friend

Church leader

Pastor

Doctor

Neighbor

Bible study member

Teacher

Boss/Work Assoc.

Work/Adjustment History

How long have you been in your current occupation?

Have you had difficulty with employment currently/in recent past?

Yes

Current Living Arrangement

With whom do you live?

Is this a satisfactory living arrangement?

Yes

If no, please explain.

Miscellaneous: Is there anything else you believe is important for us to know about you that would help this counseling experience be more effective?

Fill Out Intake Form

Spiritual Assessment Form

We invite you to take the first step in your healing journey by completing the Spiritual Assessment Form. This form is designed to help us better understand your spiritual background and current walk of faith, enabling us to provide personalized, faith-based guidance. Please answer the questions honestly and to the best of your ability. Your responses will remain confidential and will assist us in providing the support you need.

Step 1 of 2

50%

Personal Information

Please provide your Name and Email before proceeding to the next page, where you can begin the spiritual assessment.

Name(Required)

Email(Required)

SPIRITUAL ASSESSMENT

Please answer honestly and to the best of your knowledge.

Are you a Christian?

Yes

Not sure

No, but want to be

What church do you attend, if any?

How long?

Regularly

Frequently

Infrequently

Occasionally

Do you feel loved by God?

Others?

Yourself?

If you were to die tonight, do you know where you would spend eternity?

Suppose you did die tonight and appeared before God in heaven, and He were to ask you, “By what right should I allow you into My presence,” how would you answer Him?

I John 5:11-12 says, “God has given us eternal life, and this life is in His son. He who has the Son has the life; he who does not have the Son of God does not have the life.”

Are you born again according to this scripture?

When did you receive Him?

Are you plagued with doubts concerning your salvation?

Have you been water baptized?

Have you been filled with the Holy Spirit?

Are you spending time in prayer?

Are you spending time in Bible study?

Do you financially give to a ministry?

Are you currently in obedience to all that you know God has told you to do?

Is there anyone you need to forgive?

Do you need to forgive yourself?

Do you feel tormented in your mind by harmful or evil thoughts?

Please explain if you or anyone in your family have been involved in occult practices?

Have you ever had a homosexual experience?

Or thoughts?

Incestuous experience?

Other?

Have you ever had an abortion?

Or been a party to an abortion?

COMMENTS:

Home
About Us
Our Services
Fees And Scheduling
Forms
Contact

Release of Liability for Counseling Services Form

Intake Form

Fill Out Below Intake Form

Personal Information

Suicidal/Homicidal Ideation: (thoughts)

Past Psychiatric History

Medical Information

Nutrition/Sleep Patterns

Legal History

Support System

Work/Adjustment History

Current Living Arrangement

Spiritual Assessment Form

Personal Information

SPIRITUAL ASSESSMENT

Release of Liability for
Counseling Services Form