Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Communication Method *

Phone Call

Email

Text

Birthdate *

MM

DD

YYYY

Gender *

Male

Female

Prefer not to answer

How would you describe your current struggle? (Check all that apply.)

Depression

Anxiety

Marital Conflict

Sexual Issues

Victim of Abuse

Parenting Issues

Spiritual Confusion

Vocational Issues

Financial Stress

Addiction

Grief

Eating Disorder

Other

What type of counseling are you interested in receiving? Check any that apply. *

Individual Counseling

Marital Counseling

Family Counseling

Counseling for a Child (Under Age 18)

Premarital Counseling

Specific Conflict Resolution

Other

Please provide what time you are available for counseling appointments (check all that apply): *

Mornings (8am-12pm)

Afternoons (12pm-4pm)

Evenings (4pm-8pm)

What day of the week are you available (check all that apply): *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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 mentors for follow-up. Our match-decisions are based on the particulars of your registration and the areas of expertise and availability of our mentors. 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 mentor 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 mentor. 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).

Yes

I would like to discuss this further.