INTAKE FORM. General Information Name DOB Date Address: Phone: Cell Phone:

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1 INTAKE FORM General Information Name DOB Date Address: Phone: Cell Phone: Marital Status (Circle One) Single Engaged Married Separated Divorced Widowed If married how long? Number of previous marriages for you For spouse List all other persons in household and their dates of birth: Name Date of Birth Are you a U.S. Citizen? State of Birth Do you have any physical limitations that would require any additional assistance? If yes, please specify Spiritual Life Are you a Christian? If yes, how do you know? Are you part of Real Life Church? How long have you been involved at Real Life? How are you involved? Previous church attended Why did you leave?

2 Employment Information Employer Type of work qualified, trained to do? Medical Information Have you ever sought professional help from counselor, psychologist, or psychiatrist? If yes, when? Counselor/psychologist/psychiatrist name and practice: _ During that time were you placed you on any medications? If yes, what medication(s) and for how long? Are you currently taking any medications? _ Are you currently seeing a licensed counselor? Why do you want counseling?

3 Care Counseling Application The Care Counseling Program at Real Life Christian Church is a non-fee, short term, biblically based, peer support program available to members and regular attendees of the church. Sometimes space and personnel restrictions might require you to be put on a waiting list based on the date of application. Should you need immediate assistance, referrals are available. Supervision To meet our objective of providing the highest level of care possible, all counseling partners, both those that are active and those in training, are required to be in group supervision directed by the Pastor of Counseling Ministries. Confidentiality Your confidentiality is guarded at all times. Florida law does require that counseling partners have a duty to warn the appropriate individuals if the counselee intends to take harmful, dangerous, or criminal action against them. Care Counselors are also mandated to report any incidence of reasonably suspected child abuse (physical or sexual) and elderly abuse to the appropriate authorities. Counselees in a suicidal condition will be referred to therapists who are capable of providing the appropriate treatment and protection. Waiver of Liability THE UNDERSIGNED, having sought biblical counseling as such as adhered to by the REAL LIFE CHRISTIAN CHURCH a nonprofit religious organization, hereby acknowledges their understanding of the following conditions and further releases from the liability the REAL LIFE CHRISTIAN CHURCH, its agents or employees, from any claim arising from the undersigned s participation in the above-mentioned biblical counseling program, the same being identified as follows: (1) It is understood by the participant counselee, that all biblical counseling will be provided by counseling partners, not licensed therapists. (2) That all counseling provided in the biblical counseling program is provided in accordance with the biblical principles as adhered to by REAL LIFE CHRISTIAN CHURCH and are not necessarily provided in adherence with any local or national psychological or psychiatric association. (3) That no representation has been made, either expressly or implied, that biblical counseling, as conducted by the above-mentioned counseling partners, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions. Counselee (please print and sign) Date Care Counselor, RLCC (please print and sign) Date

4 Date Name EMOTIONAL ASSESSMENT From the list below, circle the words that best describe how you FEEL right now. Afraid Angry Anxious Confused Depressed Discouraged Embarrassed Forgiving Forsaken Frustrated Guilty Happy Hopeful Hurt Like Giving Up Lonely Loving Patient Peaceful Sad Tempted Threatened Troubled Unfulfilled Used Weak Worried From the list below, circle the words that best describe what you NEED. Comfort Direction Forgiveness Friends Hope Knowledge Love Patience Peace Safety Strength To Forget What word from the FEELING list is the most powerful description of your feelings? What word from the NEEDS list is the most powerful description of your needs? If the word that best describes your current feeling does not appear on this sheet write it below.

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