Christian Counseling Intake Form

CLIENT DETAILS

Date *

Client Name *

First

Last

Responsible Financial Party *

First

Last

Date of Birth *

Sex *

Email *

Phone *

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Current or Previous Occupation *

Marital Status *

Presenting Concerns: *

Briefly describe the primary reasons for seeking Christian counseling at this time.

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

Contact Number *

Relation to Client *

Mental Health History:

Type of Mental Health Services Currently or Previously Received (if any): *

Write None if never received therapy.

Therapist's Name:

First

Last

Psychiatric History (medications, diagnoses, hospitalizations):

Current Medications (if any):

May We Send Them Information? *

Therapist Email

Provider Phone

Family Background:

Family Structure (living arrangements, relationships): *

Significant Family Dynamics and Relationships: *

Family History of Mental Health Concerns: *

What specific goals or outcomes are you hoping to achieve through counseling? *

Describe any previous experience with counseling or therapy. What was helpful or not helpful?

Do you engage in specific spiritual practices (prayer, meditation, scripture reading)? Please describe *

Is there any additional information you feel is important for us to know before starting counseling? *

By providing your electronic signature below, you consent to participate in counseling services offered by signing below. *

Relationship to Client *

FINAL STEPS

How Did You Hear About Us? *

If other, please specify

Privacy Notice and Confidentiality Policy

Welcome to Nicole Sewell Transformational Coaching, Christian, and Pastoral Counseling Services.

We are committed to maintaining the privacy and confidentiality of your personal information. This notice outlines our policies regarding the collection, use, and protection of your information.

Confidentiality:

Scope of Confidentiality:
- All information shared during counseling sessions, both verbal and written, is strictly confidential. This includes any personal, spiritual, or medical information disclosed during the course of counseling.
Exceptions to Confidentiality:
- Confidentiality may be breached in the following circumstances:
  - Imminent danger to yourself or others.
  - Suspected child or elder abuse.
  - If a court order or legal obligation requires the disclosure of information.
Communication Limits:
- We cannot guarantee the confidentiality of information transmitted via email or online platforms. Please use discretion when communicating electronically.

Information Collection and Use:

Client Information:
- We collect information necessary for providing counseling services, including personal, family, and medical history. This information is securely stored and only accessed by authorized personnel.
Storage and Security:
- Client records are securely stored both in physical and electronic formats. We employ industry-standard security measures to protect your information from unauthorized access.

Your Rights:

Access to Information:
- You have the right to access and review your personal information. Any corrections or updates can be requested through formal written communication.
Retention of Records:
- Client records are retained for a period specified by legal and ethical standards. After this period, information will be securely destroyed.

Consent:

Informed Consent:
- By engaging in Christian, Pastoral counseling or coaching services with Nicole, you are providing informed consent for the collection, use, and storage of your personal information as outlined in this policy.
Changes to Policy:
- This privacy notice may be updated periodically. Clients will be notified of any significant changes.

Contact Information:

If you have any questions or concerns about this privacy notice and confidentiality policy, please contact us at coach@nicolesewell.com

Your well-being is our priority. Thank you for choosing Nicole Sewell as your partner for transformation and your faith-based counseling needs.

I have read the privacy and confidential policy. *

Yes

Sign that you have read the privacy and confidential policy. *

I would like to pay for my services

Monthly Pastoral Counseling - $149.00
Monthly Christian Counseling - $199.00
Monthly Transformation Coaching - $149.00
Hourly Pastoral Counseling - $60.00
Hourly Christian Counseling - $80.00
Transformation Coaching - $60.00
Group Coaching Per Session - $99.00
I have already paid - $0.00

A required minimum of 2 session is required to book hourly services.

Would you like to set up automatic monthly payment? *

Yes
No

Stripe Credit Card *