We welcome your call
Adult Intake Form
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.
In case of an emergency contact:
What specific issue(s) in your life are your hoping will be addressed through the counseling process?
Are your parents alive?
How was your relationship with your parents?
Were there any instances of abuse in your family?
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.
Have you ever been diagnosed with:
Have you ever felt you had/have a problem with any of the following:
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.
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.
Head to Heart Restoration Ministry is dedicated to serving the body of Christ with mercy and compassion, to bring comfort and strength to those who have been overwhelmed by the cares of this world.