Faith-Based Counseling Consent and Intake Form
Personal Information
Full Name
Date of Birth
Age
Phone Number
Email Address
Address
Emergency Contact
Contact Name
Relationship
Phone Number
Religious Background
Religious Affiliation
Current Faith Community/Church
Briefly describe your faith journey
Counseling Information
Reason for seeking counseling
Have you received counseling before?
Yes
No
If yes, please explain
What do you hope to achieve through counseling?
Consent and Agreement
I acknowledge that information shared is confidential except where disclosure is required by law.
I understand that counseling is from a faith-based perspective.
I have read and agree to participate in counseling sessions.