It is for freedom that Christ has set us free. CLIENT INTAKE FORM Name * First Name Last Name Email * Phone * (###) ### #### What days and times are you available for counseling? How did you find our services? Employer: Occupation: Birth Date: MM DD YYYY Age: Education: Hobbies: Any important family history to be aware of: Marital Status: Single Engaged Married Separated Divorced Widowed Remarried Name of Spouse/Significant other: Their Age: Their Religion: Any important relational information to be aware of: Have you dealt with severe emotional struggles in your past? Yes No Have you ever had therapy or counseling before? Yes No If yes, what were the results of your counseling? Personality Information Choose any that apply: Active Ambitious Confident Persistant Nervous Hardworking Impatient Impulsive Moody Depressive Exictable Imaginative Calm Serioius Easy-going Shy Leader Quiet Likeable Submissive Lonely Self-conscious Sensitive As you see yourself, what kind of person are you? Have you ever had an hallucination? Yes No Do you have sleeping problems? Yes No Have you had suicidal ideation in the past year? Yes No Are you on any medication for your mental health? Yes No If yes, what is the medication, or medications, you are currently taking? Rate your health: Very good Good Average Declining Approximately how much sleep do you get each night:? Have you had any weight changes recently? Yes No If so, what are the reasons for your weight loss/gain? List all important present or past illnesses or injuries or handicaps: How frequently do you consume alcohol? Daily Weekly Occasionally Very rarely Never Have you ever used illegal or excessive prescription drugs? Yes No If so, what? Have you ever experienced severe emotional upset? Yes No If so, what? Have you ever been arrested? Yes No If so, for what? Do you believe in God? Yes No Describe your faith practices: Denominational Preference: Are you currently a part of a church community? Yes No If so, describe your involvment: Do you have safe people? Yes No How do you believe God views you at this moment? List any recent changes to your religious/spiritual life: What are the issues you are currently struggling with? What are your hopes or expectations with seeking counseling? Is there any other information you'd like me to be aware of? Thank you! RELEASE OF LIABILITY FORM Name * First Name Last Name Date * This RELEASE and Waiver of LIABILITY is made and entered into on this date by and between Garden City Counseling and name as stated above (counselee). * MM DD YYYY Release * As a precondition to any and all counseling/mentoring services to be provided by the counselor, the undersigned, in consideration of the services provided by the counselor, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the mentoring relationship/services as a direct or indirect result of any involvement Mentee may have with the mentor or the mentors church or any other partnering/hosting church. * I Agree Confidentiality * Confidentiality is an important aspect of the spiritual friendship relationship, and we will carefully guard the information you entrust to us. All communications between you and our counselor will be held in strict confidence, unless you (or a parent in the case of a minor) give authorization to release this information. The exceptions to this would be: 1.) if a person expresses intent to harm himself/herself or someone else; 2.) if there is evidence or reasonable suspicion of abuse against a minor child, elder person, or dependent adult; 3.) if a subpoena or other court order is received directing the disclosure of information; 4.) if/when mentors consult with their supervision; or 5.) if a person persistently refuses to renounce a particular sin (habitual unrepentant rebellion against the Word of God) and it becomes necessary to seek the assistance of either terminating the mentoring or bring in others in the church or their family to encourage repentance, restoration, and reconciliation (Matthew 18:15-20). Please be assured that our mentors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible. * I Agree Pastoral Release Counselor may consult pastoral and counseling team when appropriate. I Agree * I HAVE READ AND UNDERSTAND ALL OF THE ABOVE: Digital Signature First Name Last Name ***Parent/Guardian if counselee is under 18 years of age: Digital Signature First Name Last Name Date * MM DD YYYY Thank you!
