Biblical Counseling Intake Form - RIM
Please complete the following form prior to scheduling your counseling/coaching appointment.
1. Diagnostic Tools: We use helpful forms such as this Personal Data Information form, and other aids, to gain an understanding of the central problems a person is experiencing. The Bible is our frame of reference to understand and change human behavior. 2. Intent Listening: We encourage the client to speak his mind in an appropriate fashion and to discuss his thoughts, anxieties, resentments, and fears so that the consultant will have a clear understanding of the central problems. In this regard, please be aware that it is our strict policy NOT to engage in communication with any client via email or over the phone. All questions and concerns will be addressed during your session with your consultant. 3. Team Counseling: There may be times when a counseling situation may call for a team approach. In this event, we may have more than one consultants involved in a session. These consultants share insights and opinions with one another which pertain to the case. 4. Assignments: Clients make more rapid progress when they are required to study or to perform specific informational or behavioral assignments which pertain to the problem. We tailor these assignments to the individual and their circumstances. 5. Accountability: We are interested in believers learning how to experience the peace and joy that result from a walk of obedience to God’s Word, and we believe it is important to hold a client accountable for doing the assignments on schedule. 6. Emergencies: In the event you have an emergency, please call 9-1-1.
Biblical counseling will vary in the amount of time required according to the individual, his motivation, and the particular problem. On the average, however, the process requires far less time than conventional secular counseling. One reason is that Biblical counselors are not interested in prolonging the number of sessions. Simple problems are often solved in one or two sessions. Severe problems may require a longer period. Addressing marital issues may require as many as 12 to 18 sessions. Substance abuse (which in a Biblical context is understood as a worship problem, idolatry) problems may require many more sessions, with intensive accountability and follow-up.
I will be charged for each 50-minute counseling session. The session fee has been communicated to me. This fee is to be paid at the beginning of each session. You may pay with cash, a personal check, credit or debit card. Phone conversations, email exchanges, and email attachments with your counselor will be charged at the regular rate in 30-minute increments. For example, if you are on the phone for over 15 minutes or an email attachment requires 20 minutes to read, you will be charged for ½ session rate. 30 minutes or more will be a full session charge. This also applies to in-person visits that take place either before or after a session. Some churches offer assistance with counseling fees. If you need assistance, you can check with your church. We are a private pay service, therefore we do not accept nor submit insurance payments.
Clients/counselees are asked to cancel appointments at least 24 hours prior to the appointment. This gives others the opportunity to use the canceled time slot. If no cancellation is made, or if less than 24-hour’s notice is received, except for absolute emergencies, then you will be charged for the appointment, as follows: one-half of your counselor's standard fee per session for the first late cancellation; a full-fee for failure to call and cancel OR for any subsequent late cancellations. If you had a double session scheduled, then the above rates also double.
Usually, anything discussed with your counselor and all information on this intake will be held in strict confidence. However, there are some situations that may have to be reported to appropriate authorities as required by law. This reporting may take place without your permission or knowledge. Reportable situations include, but may not be limited to, indications of bodily harm to self or others, involvement in a felony, suicidal intentions, and reasonable evidence/suspicion of child/elder/dependent abuse or neglect. Your counselor may also be required to disclose information in response to a subpoena issued by a court of law. Your information will not be shared without your written consent except under legal obligation or for professional consultation. There are also times when a counselor/consultant may consult with others on his or her team for advice. There may also be times when information is given to those you approve of in writing, such as an advocate or family member.
I understand that I am receiving Biblical counseling/coaching. I understand that counselors working with Relational Impact Ministries are not licensed therapists, psychologists, or Licensed Professional Counselors, are not providing me with therapy licensed by the State of Texas, and are exempt and are exempt from laws regulating professional counselors in the State of Texas under Section 503.054 of the Licensed Professional Counselor Act. I understand that at any time during the counseling process, for reasons sufficient to himself/herself, the counselor(s) or the client/counselee(s) shall have the option of terminating this agreement. I understand that information disclosed in sessions will be held confidential unless the Bible or the law requires disclosing that information.