Counseling Intake

Welcome, Dear Friend

Welcome to the counseling ministry Encounters In Joy. We are grateful that you have welcomed us into your life at this time. It is never easy to reach out for help. We admire the courage, faith, and humility this first step represents on your part.

It is our prayer that God will bless this step and use our time together to build more hope and direction into your life.

Our goal in the counseling ministry is to provide the highest quality, Christ-centered counseling to individuals and families who are hurting and confused.

Our vision for counseling is larger than a few one-on-one meetings with a counselor. Rarely does lasting change happen in isolation. We will likely encourage you to be involved in the counseling process.

Our team consists of graduate-level counselors who offer free personal or marital counseling to our community. Our team leader, Reverend Jeff Langley, is a board-certified Christian Counselor holding certifications with the Georgia Board of Examiners and Certifications in Mental Health Coaching, and Trauma and Grief coaching with Light University.

Before you begin:

You will need approximately 45 minutes to complete these forms. The form covers policies, personal background, spiritual and health information, and your counseling goals.

You can also download the PDF version to print and complete by hand.

Important notes:

Childcare is not provided. Children are not allowed to sit unattended in waiting areas or in counseling sessions unless requested.

If you are taking prescription medication(s), please do not alter your dose on the day of your appointment. If you have recently begun a new medication, please allow approximately two weeks before scheduling.

In Christ,
Reverend Jeff Langley, BCCC
Encounters in Joy Ministries
"What began in the Garden ends at the Cross."

Policy Review

Ministry Policies

Please read each policy carefully and indicate your agreement by checking the box.

Your Rights as a Counselee

You have the right to discuss possible outcomes and challenges regarding counseling and receive an estimate of predicted length, goals, and outcomes. You have the right to ask about and/or refuse any techniques used. You may conclude counseling at any time, but we encourage you to consult with your counselor as to the best way and time to do so.

Not Professional Advice: If you have legal, financial, medical or other technical questions, you should seek advice from a professional with expertise in those fields.

Financial Policy

Encounters In Joy is part of our ministry to our community. We do not charge for the counseling services offered. The graciousness and generosity of donators allows us to offer these services free of charge. We would encourage you to make a contribution in response to the counseling you receive.

I understand and agree with this Financial Policy

Appointment Cancellation Policy

We request a 24-hour notice if you wish to cancel or are unable to keep an appointment.

$25.00 for appointments missed or cancelled with insufficient notice.

I understand and agree with this Cancellation Policy

Philosophy of Care

We are committed to providing a balanced and Biblical approach to counseling. By biblical counseling we mean that your counselor is a Christian with special training and experience in applying the truths of the Bible to life.

We believe the Bible ultimately points us to a person and a relationship — Jesus Christ as our Savior and Redeemer. We believe that real change comes when people learn to see themselves and their problems in the context of a living, vital relationship with Christ.

This does not mean that you must be a Christian to profit from our counseling, although we believe that deep and lasting change is brought about only by God himself. The Bible is never brought to bear in an artificial or heavy-handed way.

I understand and agree with this Philosophy of Care

Confidentiality Clause

Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. As a Christian-based counseling center we do not promise absolute confidentiality. Your counselor reserves the right to consult with other counselors at Encounters In Joy and supervisors for the purpose of providing the highest level of care.

Exceptions when information may be shared include: known or suspected child or elderly abuse; intent to take criminal actions or violence against another person; active suicidal thoughts or intentions.

As a Christian Counseling Ministry, our counselors are not agents of the state. Conversations and notes may not be admissible in court. By agreeing, you agree not to attempt to subpoena any counselor or notes related to this counseling.

In marriage or family counseling, confidentiality belongs to the relationship, not the individual.

I understand and agree with this Confidentiality Clause

Waiver of Liability

By agreeing, you acknowledge:

Counseling will be provided by graduate-level Christian Counselors or interns, not licensed as LPC, LMFT, LCSW, or LFBPPC through the state of Georgia.
All counseling is provided in accordance with biblical principles and not necessarily in adherence to any psychological or psychiatric association.
No representation has been made that biblical counseling is accepted as customary psychological and/or psychiatric therapy.
All complaints and grievances will be heard by the organizational leadership of Encounters In Joy.
This is a voluntary program in which you are choosing to participate.

I understand and agree with this Waiver of Liability

Consent

Consent to Counsel

Having read and understood the policies, please provide your consent below.

Your Full Name (print) *

Date *

Names of others who may be involved in the counseling process

I understand that Encounters in Joy may terminate services for noncompliance with the plan of care, failure to keep or cancel appointments, violent behavior, threats of violence, involvement in criminal behavior, or similar issues.

Firearms of any kind (including concealed weapons) are prohibited inside all areas of Encounters In Joy counseling offices.

I have read the policies in this document I agree with and understand each of these policies I am enrolling myself into counseling of my own will

Digital Signature (type your full name) *

Spouse/Second Counselee Signature (if applicable)

About You

Personal Information

This information helps your counselor get to know you.

Full Name *

Gender

Age

Address

Primary Phone May we leave a message?

Second Phone May we leave a message?

Occupation / Employer

Avg Hours/Week

Date of Birth

Email Address

Highest Degree Earned

School

With Whom Do You Currently Live (check all that apply)

Family

Marriage & Family

Complete if you are currently married, engaged, or dating.

Name of Spouse

Spouse's Age

Spouse's Address (if different)

Spouse's Phone

Spouse's Email

Spouse's Occupation / Employer

Is spouse willing to come?

Have you ever been separated?

Date of Marriage

How long did you know spouse before marriage?

Length of engagement

Previous Marriages (if any)

Children

List each child: name, age, gender, whether living at home, married, any special conditions.

Faith

Spiritual / Religious Information

Help us understand your spiritual background.

Church Name

Years at Church

Ministry Involvement

Have you been baptized?

Spouse's religious background

Do you pray to God?

Have you received Jesus Christ as your Savior?

What does spirituality mean to you?

Any recent changes in your spiritual life?

Health

Health Information

Your physical and mental health background.

Bio-Psychological Questions (Yes/No)

Have you ever felt people were watching you? Do people's faces seem distorted? Difficulty distinguishing faces? Do colors ever seem too bright? Have you ever had hallucinations? Are you plagued by fears? Do you have problems sleeping? Do you hear voices? Ever thought of committing suicide? Have you ever been arrested? Recently suffered the loss of someone close?

Have you had counseling before?

Seen a psychiatrist before?

If yes, describe previous counseling

Hours of sleep per night

State of current health

Current illness, injury, or disability

Current medications (name, dosage, frequency, prescribed for)

Used drugs for non-medical purposes?

Do you drink alcoholic beverages?

Describe your eating habits / exercise routine

Distress Level (1 = very little, 10 = extreme)

1 - Very little510 - Extreme