Adult Intake Form

This form is only for use after new clients have filled out our contact form and scheduled the first session with a counselor. Have you already taken both of those steps? Select your answer using the dropdown field.

Both steps taken?

Please click this link to our contact form and fill out your details so we can schedule a time to learn more about how we can help.

Instructions: Please complete the survey as accurately as possible, including any information that you feel could benefit the counseling process. All information contained in this survey is confidential except as prohibited by state / federal law regarding major criminal offenses and child, elderly, or disabled persons abuse.

∗	= required field

PERSONAL INFORMATION

First Name *

Last Name *

Gender *

Counselor's name *

Address Line 1

Address Line 2

City

State

Zip

Cell Phone *

Work Phone

Email *

Employer

Current Profession

Age

Your Children

#1

Gender

Age

Lives in the same house

#2

Gender

Age

Lives in the same house

#3

Gender

Age

Lives in the same house

#4

Gender

Age

Lives in the same house

#5

Gender

Age

Lives in the same house

Emergency Contact Information

In case of an emergency contact:

First Name

Last Name

Relationship to you

Cell Phone

Work Phone

Email

REASON FOR SEEKING COUNSELING

What specific issue(s) in your life are your hoping will be addressed through the counseling process?

Family Background

Are your parents alive?

Father

Your age at time of death

Mother

Your age at time of death

Are they living together

Are they divorced

Are they separated

Is your father remarried

Your age when he remarried

Is your mother remarried

Your age when she remarried

How was your relationship with your parents?

Father

Mother

Siblings

#1

Gender

Age

#2

Gender

Age

#3

Gender

Age

#4

Gender

Age

#5

Gender

Age

Where do you fall in the birth order?

How was your relationship with your siblings growing up?

Was yours a basically happy or unhappy home during childhood?

Were there any instances of abuse in your family?

VERBAL

By whom

To who

EMOTIONAL

By whom

To who

Physical

By whom

To who

Sexual

By whom

To who

Alcohol

By whom

Substance

By whom

Spiritual History

Note: The counseling provided will be conducted from a faith based perspective. While the counselee does not have to be of the Christian faith they understand that issues of faith will be an important component of the counseling process.

What is your religious or church background?

Are you currently active in your church

How would you describe your relationship with God

Mood Inventory

Note: The counseling provided will be conducted from a faith based perspective. While the counselee does not have to be of the Christian faith they understand that issues of faith will be an important component of the counseling process.

Change in eating habits (poor appetite/overeat)?

Change in sleeping patterns (insomnia/oversleeping)?

Lack of motivation/energy for ordinary tasks?

Feelings of hopelessness?

Poor concentration & difficulty making decisions?

Have you personally ever received psychiatric treatment?

Feeling mentally confused?

Self medicate (through alcohol, sex, food, work, entertainment, etc.)?

Have short term memory loss?

Have panic attacks?

Hear voices in your head?

Are you now undergoing psychiatric treatment?

Have you ever been diagnosed with:

Depression

Schizophrenia

Obsessive compulsive disorder

Attention deficit disorder

Anxiety disorder

Bipolar

Other

Please describe

Has any member of your family ever received psychiatric treatment?

Who, and what was the diagnosis?

Are you currently on medications?

Which medications, and to treat what?

Addiction Inventory

Have you ever felt you had/have a problem with any of the following:

Alcohol

Substances

Tobacco

Food

Gambling

Pornography

Sex

Other addictions

Please describe

Has a family member been addicted to any of these?

Who is / was addicted, and to what?

Personal Inventory

Describe yourself in as many one or two word phrases as possible:

Additional Inventory

Additional information you feel is important to the counseling process.

Statement of Understanding

The mission of Head to Heart Restoration Ministry is to provide emotional and spiritual wholeness to broken and wounded people through the power of Jesus Christ. Head to Heart Restoration Ministry is a 501(c)3 nonprofit pastoral counseling ministry. Persons receiving counseling/ministry understand that:

Counseling is faith based Christian counseling. Counselors are ordained ministers or “Domestic Missionaries” with a counseling focus. In addition to talk/cognitive therapy, counseling techniques include prayer, the use of scripture, and biblical principles.

Counselors are not licensed by the State of Texas as Licensed Professional Counselors.
Clients have a right to confidentiality, although it is not an absolute right. Common reasons confidentiality may be violated include:
- Client is suspected of physical or sexual abuse or neglect towards children, the elderly or the disabled.
- When a client discloses their involvement in physical or sexual abuse or neglect towards children, the elderly or disabled.
- When a client is in danger to self.
- When a client is in danger or as threatened to harm others.
- When a client appears gravely disabled and unable to make a rational decision as to his or her need for emergency treatment.
- When a client appears in medical crisis and unable to grant permission for release of information.
- When there is a court subpoena for client records or information.
- Head to Heart Restoration Ministry counselors have a right to consult with each other regarding client issues, while maintaining confidentiality within the organization/ministry.

Counselors will not testify in court or release counseling notes or documents on behalf of clients unless required by a court subpoena. This includes testifying on behalf of clients for divorce or child custody hearings.
Counselors are not licensed attorneys and/or medical doctors. Information provided is strictly opinion and is not intended to be legal and/or medical counsel or clinical diagnoses.
Clients are fully responsible for all decisions they make in regards to counseling recommendations and/or suggestions.
The termination of the counselor/client relationship occurs when:
- The client informs the counselor that they do not believe they need additional counseling
- The client does not schedule additional sessions
- The client does not call to reschedule or show up for a scheduled session
- The counselor recommends that the client be referred to another counselor or professional
- The client and counselor mutually determine that counseling services be discontinued
- Non-payment of agreed upon fees
Fees for counseling services are required at the time of the appointment. The standard fee is $85 per session. There is a $3 per transaction fee per credit card payments.
If a reduced rate or financial assistance is being requested, a Reduced Rate, Sliding Scale and Benevolence Fund application is required. The number of sessions available for reduced rate clients may be limited.
Client’s will be billed the full session rate for cancellations not made 24 hours in advance.
Not showing up and not canceling in advance will result in full session payment.

Fee Information

Fees for counseling services are required at the time of the appointment. The standard fee is $85 per session. If a reduced rate or financial assistance is being requested, a Reduced Rate, Sliding Scale and Benevolence Fund application is required. The number of sessions available for reduced rate clients may be limited.

There is a $3 per transaction fee for all credit card payments. Client’s will be billed the full session rate for cancellations not made 24 hours in advance.

Date *

Initial to sign *

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