Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Communication Method
*
Birthdate
*
MM
DD
YYYY
Gender
*
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Remarried
Do you attend a church?
*
Yes, regularly
Yes, occasionally
No
Name of Church (if you attend a church)
How would you describe your current struggle? (Check all that apply.)
Please provide a brief summary of what prompted you to pursue counseling at this time. Feel free to include any information about your current circumstances, relationships, symptoms or stressors that might be helpful for us to know.
What type of counseling are you interested in receiving? Check any that apply.
*
Are you currently seeing (or have you seen in the past 2 months) a counselor?
*
If you were referred to counseling, can you share who referred you?
Please provide what time you are available for counseling appointments (check all that apply):
*
What day of the week are you available (check all that apply):
*
Is there any additional information you would like us to know?
I have read and agree to the following confidentiality statement.
*
We are committed to maintaining any information our registrants entrust to us in a confidential manner. Your intake form will be carefully reviewed by a Redemption Counseling Ministries (RCM) counseling ministry leader (and the leader at your church who oversees counseling -- usually the lead pastor) and then referred to one of our lay counselors for follow-up. Our match-decisions are based on the particulars of your registration and the areas of expertise and availability of your church's lay counselors.
We are committed to do everything possible to guard any information you entrust to us. However, there are times when we are legally required and/or biblically obligated to share information with others. Some exceptions to confidentiality include, but are not limited to the following: 1. We are informed of alleged or suspected child/elder abuse or neglect committed by or experienced by the registrant or by a specifically identified individual, 2. The registrant is a perceived threat to himself/herself or others, 3. The staff is subpoenaed and ordered by a legal authority to testify or release registrant information, 4. The registrant or parent/legal guardian of the registrant provides a valid, written consent to release information to a third party, 5. The parent/legal guardian of an individual under the age of 18 requests information about the child.
To help ensure that you get the best possible care, your lay counselor will consult monthly with their supervisor (at RCM and the counseling ministry leader at your church), which means that your case may be discussed for the purpose for providing accountability and direction for your lay counselor. On rare occasions, we may also confidentially consult with an appropriate professional colleague to seek greater wisdom in order to provide counselees with the best possible counsel.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns you may have. Where possible, we attempt to discuss the situation with our counselees before any action is taken. When you submit this form, it will be sent by email to the RCM counseling team and the counseling leader of your church (if you are part of an RCM partner church).
