Intake Application

Name *
Briefly complete the following (please use additional paper or back of form if necessary)
Describe Below
Please List Times Per Month Below
Describe Below
Please List Times Per Month
If Answered Yes to the above question explain When?
Please Initial Below
Go to bed? Fall asleep? Wake up? Get out of bed?
Use Extra Paper or Back of Form to list medications if needed
Lost And Gained
Husband And Wife
Husband Wife
check this column if child is by previous marriage
I do NOT receive a salary or pay of any kind. A DONATION of $40 or more to OPEN HEARTS MINISTRIES is asked This is a TAX DEDUCTIBLE DONATION PAYABLE BY CASH, CHECK OR CREDIT CARD
I/We affirm the accuracy of the personal information provided herein, have read the information and agree to the conditions set forth therein. I/We hereby agree to the following conditions: 1. I am (We are) committed to seeking new insights into a personal, love relationship with Jesus Christ, which may involve new understandings from God’s Word, and to pursuing a transformed life (lives) that reflects) God’s grace as revealed in His Word. 2. I (We) will fulfill the weekly assignments or the session might not be held. 3. I (We) will consistently attend a Biblebelieving church each Sunday while I am (we are) in counseling. 4. I (We) will keep the appointment time, or will call to cancel 24 hours in advance. (Except for absolute emergencies)
Confidentiality is an important aspect of the counseling process. We carefully guard the information you entrust to us to the fullest extent possible. There are exceptions when counseling information may be shared outside the Healing Hearts counseling context . Those exceptions would include, but are not limited to the following: (1) known or suspected child abuse or elderly abuse of any kind; (2) the intent to take criminal actions or violence against another person; (3) active suicidal thoughts or intentions; and; ( 4 ) other credible intent to harm self or others; and (5 ) matters of church discipline (see Matthew 18:1517). Counselors reserve the right and discretion to contact any and all appropriate entities when, as a result of the counseling, it is clear that a crime has been committed or is about to be committed or the safety and welfare of any person (including the counselee) is in jeopardy. The counselor is not required to notify the counselee in advance of any such contact with the appropriate entities. In the case of marriage or family counseling, there is limited confidentiality, meaning the confidentiality belongs to the relationship and not to the individual .
Healing Hearts Counseling Office 611 N. College Ave. ElDorado, AR 71730 (At the corner of Grove and College in the A-PLUS Insurance Office Building.) What should I bring? bring your Bible and a notebook to each appointment.
Having clearly stated the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body. If you have . If these guidelines are acceptable to you, please sign below. Signed Bro. Steve EMAIL…..
Print your name: _____________________________________________________ Signed: _____________________________________ Date: __________________ Counselor: __________________________________ Date: __________________ Assistant Counselor: __________________________ Date: __________________