Biblical Counseling Intake Form - RIMPlease complete the following form prior to scheduling your counseling/coaching appointment.Please enable JavaScript in your browser to complete this form.Please Choose the Biblical Counselor You desire to meet with *Tim RussoElaine RussoI have no preferenceName *FirstLastAddress *City *State *Zip Code *Emergency Contact (Full Name) *Emergency Contact Phone Number *Are you currently serving in the military or have you served? *Currently servingPreviously servedI have no military experieinceWhat type of counseling are you requesting? *MarriageFamilyIndividualOther/UnsureDate of MarriageIf you were referred by someone, please type their name in the box belowEmail *Phone *Date of Birth *Gender *MaleFemaleOccupation *Marital Status *Single (never married)EngagedMarriedSeparatedDivorcedWidowedSpouse's NameSpouse's EmailSpouse's OccupationIf engaged, for how long?If separated, for how long?If divorced, for how long?If widowed, for how long?How many times have you been married? *0123more than 3How long were you previously married?List names and ages of children with your current spouse.List names and ages of children with your former spouse.What type home did you grow up in?Traditional (Mom and Dad)DivorcedSingle ParentStep FamilyOther FamilyHow would you describe the home you grew up in?Affectionate (emotions appreciated)DysfunctionalAuthoritarianHypocriticalVery StrictReligiousNeglectfulAbusivePlease DescribeDo you consider yourself a born-again Christian? *YesNoUncertainAt what age were you converted to Christ?How much do you read/study your Bible? *OftenOccasionallyNeverAre you actively involved in church or Christian community)? *YesNoName and location of church or Christian community.How long have you attended?Do you have an accountability partner? *YesNoHow would you rate your overall health? *1 (worst)2345 (best)List current medications/dosage/ length of time you have been taking them.Have you had any sudden weight changes in the last 12 months? *YesNoPlease explainHave you recently or are you currently using any drug other than for medicinal reasons? *YesNoPlease explainHow many hours of T.V. do you watch per day?Do you drink coffee or caffeinated beverages?Yes, 1-2 per dayYes, 3-4 per dayYes, more than 4NoDo you smoke?YesNoSometimesDo you consume alcoholic beverages? *Yes, dailyYes, weeklySometimesRarelyNeverDo you tend to explode with anger? *YesNoDo you tend to withdraw when angry? *YesNoDo you frequently argue with others? *YesNoHave you ever felt people were watching you? *YesNoDo people's faces ever seem distorted? *YesNoDo you ever have difficulty distinguishing faces? *YesNoDo colors seem too bright? *YesNoAre you sometimes unable to judge distance? *YesNoAre you afraid of being in a car? *YesNoIs your hearing exceptionally good? *YesNoDo you have problems sleeping? *YesNoWhat is the MAIN PROBLEM as you see it (what brings you in for counseling?) *What have you done about it? *How long have you been experiencing the problem? *Is this a recurring problem? *YesNoWhen was the last time it occurred? *What do you hope to achieve through the counseling process? Briefly state two or three goals. *What further information about yourself should we know?Check the areas you are currently experiencing problems in. *EnvyBitternessDepressionFearHealthIn-LawsMoodinessSleepAngerChange in lifestyleDeceptionGluttonyHomosexualityAppetiteRebellionSpouse abuseApathyChildrenAnxietyGuiltImpotenceMemorySexA ViceOtherPLEASE INDICATE WHICH OF THE FOLLOWING PERTAIN TO YOU *My parents divorced when I was a child.I had no father/mother growing up.One of my family members committed suicide.I have had one or more abortions.I was given up for adoption.Was adopted.I was sexually abused.None of the aboveIs there other information about you that you would like us to know?COUNSELING/COACHING INFORMATION AND RELATIONSHIP *I understand the following statement1. 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.LENGTH OF BIBLICAL COUNSELING/COACHING *I understand the following statementBiblical 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.SERVICE AND FEES *I understand the following statementI 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.MISSED APPOINTMENTS AND LATE CANCELLATIONS *I understand the following statementClients/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.ABOUT CONFIDENTIALITY *I understand the following statementUsually, 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.COUNSELING/COACHING AGREEMENT *I understand the following statementI 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.I AGREE TO THE FOLLOWING. CHECK EACH BOX. *I am committed to changing my life by coming into obedience to the Word of God.I will keep the appointment time, or will call to cancel in advance with a legitimate reason.I will fulfill the weekly assignments.I will do my best to be regularly involved in my church community while I am in counseling.I understand that confidentiality cannot be guaranteed in the case of information as indicated above.Name *FirstLastAGREEMENT CONFIRMATION. *I agree to the terms of this agreement.Submit