Client Name

First Name

Last Name

Gender

Male

Female

Age

If minor (17 & under) - parent/guardian name

Marital Status

Single

Married

Divorced

Separated

Widowed

Spouse's Name (if applicable)

First Name

Last Name

Seeking

Individual counseling

Couples counseling

Family Counseling

Counseling for a minor child (15 & Under)

Referred by: (Pastor/Church, Family Member, Friend)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Text Messages

Do we have permission to send text messages to your cell phone for reminders or resources?

Yes

Can we leave a message?

Yes

Briefly describe reason(s) for seeking counseling

Have you met with a CLM counselor in the past? If so, who?

What do you hope to accomplish in counseling?

Pledge

HOW WE OPERATE FINANCIALLY: CLM is a pledge-based ministry. We do not have a set fee for counseling because we do not want finances to be the reason you do not seek biblical counseling. To help you determine what you want to contribute, please consider the following information: - Pledging $120 per counseling hour would cover all expenses to run as a ministry. However, because not all clients can afford this amount we ask you to pledge an amount appropriate for you. - The amount of money you pledge goes directly to the counselor spending time with you. - Any amount contributed over $50.00 per 1-hour session is considered a tax-deductible donation. (Example: Pledge $70 and $50 will go toward the service of counseling. The remaining $20 will be reflected on a Charitable Donation Receipt mailed at the end of the year.) - Contributions may be made via cash, check, debit or credit card at the end of your counseling session. - The cost of any assigned material such as books, CD’s, or online downloads will be in addition to your pledge and yours to keep. Insurance Filing: Most insurance companies do not reimburse for biblical counseling services. If your insurance company does cover this service we ask that you do your own filing. We can provide any requested information. Pledge amount per 1-hour session: (Typically $50-$75)

Client Agreement

The best counseling experience happens when both client and counselor work together. We ask that you commit to the following: 1. Honesty & humility throughout the counseling process. 2. Keeping your counseling appointments, unless urgent matters interfere, in which case we would request that you notify us as soon as possible. 3. Completing your homework assignments. 4. The Word of God, the Bible, will be the highest source of authority. 5. At the conclusion of the counseling process, a Release Session will be scheduled to discuss any recommended assignments to encourage continued growth and health. If you have read, understand, and agree to all of the above statements - your name in the box below will serve as your signature: (If the client is a minor, please sign as the parent/guardian)

Confidentiality & Release of Liability

I understand that this counseling is not a medical or psychiatric service, but is exclusively the sharing and explaining of principles set forth in the Bible as applied to my personal situation. I have voluntarily sought counseling at Christian Life Ministries. I am under no obligation or compulsion to accept this counseling or any advice I may receive during this counseling process. I further agree to hold Christian Life Ministries and its staff free from any and all liability, loss or damage of any kind that may arise as the result of the counseling. I understand that Christian Life Ministries and any employee or other representative of CLM is offering this counseling voluntarily, at a voluntarily pledged cost, and that I or CLM can terminate or limit this counseling at any time. I understand that any counselor representing Christian Life Ministries will respect and protect my right to confidentiality, however, the counselor has the freedom to disclose any information received in the following circumstances: 1. The information may be disclosed to law enforcement officers or other government officials if the counselor believes that the information may be an actual, threatened or potential crime, other violation of law, or other matter within the responsibilities of the officers or officials to whom the disclosure is made. 2. The information may be disclosed to whomever the counselor feels should have it, if the counselor believes it is about an actual, threatened or potential suicide, or other act of self-harm. 3. The information that minors disclose regarding abuse, illegal activities, social dangers or abortion may be disclosed to parents or other appropriate authorities if the counselor believes such disclosures will enhance the counseling process or provide necessary protection for the minor. 4. The information may be disclosed to my spouse, if the counselor believes that this may strengthen the marriage relationship or correct a misunderstanding in the mind of my spouse. 5. The information may be disclosed to other counselors representing CLM, as part of the normal assistance counselors give to each other to enhance their effectiveness. If you have read, understand, and agree to all of the above statements - your name in the box below will serve as your signature: (If client is a minor, please sign as the parent/guardian)

YOU’RE ALMOST DONE!

Your intake has been submitted. NEXT, print the Detailed Intake or if client is 15 years of age or under, print the Adolescent Intake. Please fill out and bring to the first appointment.

We will call & email you as soon as you have been placed with your counselor(s). Please check your inbox and spam folder for further communication from connect@clmrapidcity.com

Before your first appointment: