Intake Form – Less A Seed Falls

Individual Support Intake Form

Individual support intake form

NOTE: THIS INFORMATION IS CONFIDENTIAL

NAME

DATE

EMPLOYER

POSITION & TITLE

HOW DID YOU HEAR ABOUT “LESS A SEED FALLS TO THE GROUND?

PRESENTING PROBLEM: PLEASE STATE IN YOUR OWN WORDS THE MAIN REASON THAT YOU ARE SEEKING INDIVIDUAL SUPPORT

HAVE YOU SOUGHT OUT SUPPORT FOR THIS OR ANY OTHER CONCERN BEFORE? [YES or NO] IF YES, WHAT WAS YOUR ISSUE OR CONCERN THEN?

IF YES, WHAT WAS THE RESULT OF THE MEETINGS OR SESSIONS?

IF YES WHO WERE YOUR MEETINGS OR SESSIONS WITH I.E. [ A COUNCELOR, A PASTOR, A THERAPIST, A PSYCHIATRIST, A PSYCHOLOGIST ETC?]

USING ONE OF THE INDICATORS BELOW, PLEASE STATE TO WHAT LEVEL OF SENCERITY AND DEDICATION YOU ARE AT, AT THIS TIME, TO ANSWEREING THE CALL YOU FEEL IS ON YOUR LIFE?

MARITAL STATUS

NUMBER OF KIDS

HOW MANY SONS

HOW MANY DAUGHTERS

YOUR SONS AGES

YOUR DAUGHTERS AGES

YOUR AGE

STATE SPECIFICALLY WHAT YOU BELIEVE HAS BEEN YOUR BIGGEST OBSTACLE OR OBSTACLES TO MOVING FORWARD

IN ADDITION TO BEING SUPPORTED, ENCOURAGED AND LISTENED TO, ARE YOU ALSO WILLING AND READY TO BE CHALLENGED IN SOME AREAS OF YOUR LIFE?

ARE YOU WILLING TO BOTH EXAMINE AND RE-EXAMINE SOME OF YOUR PAST OR CURRENT WAYS, THOUGHTS AND OR PRACTICES THAT MAY HAVE BEEN CULPRITS IN HOLDING YOU BACK?

ARE YOU WILLING TO IMPLIMENT ANY NEW OR NEEDED CHANGES, IDENTIFIED, THAT MAY BETTER HELP YOU?

WHEN WOULD YOU LIKE TO GET STARTED? THIS WEEK

DISCLAIMER

THIS FORM MUST BE SIGNED BEFORE PROCEEDING WITH SERVICE[S]

I AM NOT A LISCENCED THERAPIST, COUNCELOR, PSYCHIATRIST OR PSYCHOLOGIST ETC. THIS SITE IS NOT ESTABLISHED BY AN OFFICIAL COUNCELING GROUP, BUT RATHER THIS SITE IS ESTABLISHED AS A SUPPORT SERVICE, WHERE, HERE A SERVICE IS PROVIDED TO SUPPORT SPECIFIC AND VETTED INDIVIDUALS IN NEED OF SOMEONE TO TALK/SPEAK TO IN AN UN-OFFICILAL CAPACITY. ALL MEETINGS, SESSIONS AND CONFERENCING WILL BE MADE WITH THIS UNDERSTANDING IN MIND, BY ALL PARTIES INVOLVED, PRIOR TO ENGAGEMENT.

YES, I UNDERSTAND THAT THIS IS A SUPPORT SERVICE NOT A PROFESSIONAL COUNCELING GROUP OR SESSION. AND, I AM OF SOUND MIND AND SIGNING OF MY OWN VOLITION AND WOULD LIKE TO PROCEED.

NAME [PRINTED]:

SIGNATURE: _______________________

Date: