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Basic Information:

Name
Preferred Method Of Contact
Address
Marital/Relationship Status
Children

What Brings You Here?

What would you most like help with? (check all that apply)

Tell Me More

How is this affecting your everyday life?

Your Goals

How ready do you feel to actively work toward change?

Family and Relationships

Are there currently significant conflicts or changes within your family?

Faith and Spiritual Life

*My approach can incorporate Christian principles and biblical perspectives when desired. Your responses to this section help me understand how you would like faith addressed in our work

How important is faith in your everyday life?
Would you like Christian faith and biblical principles incorporated into our work?
Are you currently connected to a church or faith community?

Emotional Well-Being and Previous Support

These questions help determine whether the services I provide are appropriate
for your current needs

Have you previously received counseling, therapy, coaching, psychiatric care, or another form of emotional/behavioral support?
Are you currently receiving services from a therapist, psychologist, psychiatrist, physician, counselor, or another mental-health professional?
Have you ever been diagnosed with a mental-health, developmental, behavioral, or neurological condition?
Are you currently taking medication related to your emotional or mental health?

Current Well-being Check

During the past two weeks, have you experienced any of the following?

Safety Check

Your safety matters. These questions help determine whether you may need a level of support beyond the services provided here

Are you currently experiencing thoughts of harming yourself?
Have you recently had thoughts that you would be better off dead or that you do not want to be alive?
Do you currently feel unsafe in your home or relationship?
Are you currently experiencing thoughts of harming another person?
Are you currently experiencing abuse, violence, threats, stalking, or coercion?

*Important: This form and my services are not emergency or crisis-response services. Submission of this form is not continuously monitored and should not be used to request emergency assistance. If you believe you or another person is in immediate danger, contact emergency services or an appropriate crisis resource in your area.

For parents or guardians seeking support for a child

Complete this section only if services are being requested regarding a child or adolescent.
Child's Name
Where do the concerns occur?
Has the child's school or another professional expressed concerns?
Has the child previously received any evaluations, diagnoses, counseling, therapy, behavioral services, speech/occupational services, or educational accommodations?

Strengths and Support

I don’t only want to understand what is going wrong. I also want to understand what is already strong

What would you like from me?

What type of support are you currently seeking?
How did you find me?

ACKNOWLEDGMENT
I understand that completing this intake form is part of an initial assessment process and does not, by itself, establish a professional service relationship.

I understand that the information I provide will be reviewed to help determine whether the services offered are appropriate for my needs. I understand that I may be encouraged to seek services from another professional or provider when my needs fall outside the scope of the services offered.

I understand that these services are not a substitute for emergency services, crisis intervention, medical treatment, psychiatric treatment, or other specialized clinical care when those services are needed.

I understand that Christian or biblical principles may be incorporated according to
my preferences and the nature of the services being provided.

I confirm that the information I have provided is accurate to the best of my knowledge.

Client/Parent or Guardian Name:
Date / Time