This form gives us understanding of your overall need for outpatient counseling. It covers your current issues, what we call your presenting problem, and it covers the depth of other things that may be prominent in your life.
If we start with the foundation of your history, it gives us a Headstart on our counseling process. We can also turn back to it, to reference again.
Thanks for filling out the intake forms. The first one is called a “Consent Form”. This tells you about counseling, confidentiality, and lays out all the criteria for coming to a counseling appointment. NHL find payment information, scheduling, emergencies, and numbers to call for scheduling and emergencies.
Counseling is done with consent only. This means there has to be agreement but either the person coming to counseling, or the legal guardian in the case of a minor. If there is a minor whose parents have been divorced, there has to be proof from the divorce decree that the parent bringing this MINOR has legal decision-making for medical issues for the minor.
What’s Behind Our Intake Form
Our intake form begins with this: “Thanks so much for coming in today. We are both honored and privileged for the opportunity to earn your trust and become a small part in your healing journey. We believe that embracing “kingdom living” means that each person that crosses another’s path is not by any accident, but by divine design. It is our heart to truly understand where you have been, where you are now, and where you are proposing to go. Help us to walk beside you effectively by prayerfully answering the following questions with brief answers that abide in your “heart’s truth.”
What are the current issues that are bothering you today? Here, please tell us about the things that are really on your heart that have been coming up in the last few days and weeks. Please, especially, tell us the thing that really triggered you coming in today. This could be a crisis or a situation that has come up very recently. Or it could be something that has been building over a long period of time. Also, it could be something that you have been putting off getting counsel for but now is the time.
What are situations or behaviors that bother, irritate, or “push your button(s)” over and over? These are commonly called triggers. What are triggers in your life situation or behavior of others or yourself that you find yourself over reacting to perhaps with anger maybe with fear maybe with sadness. Oh this is the time to be honest with yourself about possibilities that could give us clues about what’s going on in your life. These may be ongoing triggers or recent triggers. Very often a trigger or something that is pushing your buttons, means that you have the pain of a current circumstance combined with the pain of the circumstance from the past that is unresolved.
How would you best describe your need for ministry? I technically this is counseling or therapy from a licensed therapist, but if you’re Christian counselors like we are you consider it a ministry. So we ask you “how would you best describe your need for ministry?” What definition of ministry is this: “To attend and serve; to perform service in any office, sacred or secular.” How can we best attend to your needs and offer counsel to you?
What are the most vivid memories that you have from your early life? Often your memories from the earliest part of your life give us great clues but some of the earliest memories are often remembered because they are traumatic. about things that might be affecting you today. These could be positive or negative, often traumatic.
Name any/all dominant themes of your life that bring negativity and struggle to your daily life. The sections to help us understand things trip you up on a regular basis. It could be as simple as negative self talk, holding grudges, or losing your temper. It might be something about anxiety or worry. It could be any number of things that have been dominant in your life, past or present.
Rate the following self negativity on a 0-10 scale, with 0 meaning it does not feel true and 10 meaning it feels totally true.
There’s a legitimate shame which we might say is just conviction and there’s illegitimate shame which we might say is condemnation. If you struggle with feeling condemned by yourself or others then this would be higher if not you would put this lower.
This is going to be higher if you’re hard on yourself, if you often have resentment toward yourself, or you often find yourself feeling really negative towards yourself.
This is about your ideas, your thoughts, your words and your behavior seem to be exalted or given the rightful respect or constantly put down by yourself or others, But especially by others.
This could be personified by never feeling worthy of gifts or accolades or encouragement. Or a constant negativity about your significance.
This was commonly behind if you have things from your past that you found a great difficulty shaking. You carry guilt and you find that it’s hard to get free from it.
I guess powerlessness may be about things from your past or things from your current life that feel significantly out of control. Sometimes it’s when you feel very weak in tackling a particular relationship or situation. Or circumstance
This is typically related to something we can wait till shameful about. It could be associated with sexual abuse in your past, or something that you feel particularly guilty about, but somehow or other you’ve ended up feeling unclean or tainted because of what you’ve done, or because of what someone has done to you.
Afraid/ In Danger:
You will get this if it applies to you, but if you find that you’re consistently anxious, fearful or worrying, you would score high on this. This is often a sign of unresolved trauma from the past.
The remaining questions on the intake form are as follows:
Briefly add additional comments pertaining to the emotions table if necessary.
What are the most traumatic/disturbing experiences that you have been through (especially in your early years) in the following areas of your life?
This is self-explanatory.
if you’ve been through physical trauma, assaults, physical abuse, accidents, hospitalizations, that were injuries to your body either accidentally or on purpose or even by your own self harm?
Sexual: Have you experienced sexual trauma through sexual abuse, addiction or any kind of rape?
Emotional abuse includes yelling, manipulation, silent treatment and intimidation among other things.
Trapped, held down, or restrained against your will:
What are things physically or otherwise that you have felt powerless in your life.
Have you been challenged, put down, teased or maligned for not being smart enough?
What do you think God is telling you to face or deal with at this time? Self Explanatory.