Thank you for contacting Calvary Counseling Center in regards to how we might be able to walk alongside you bringing light to your path from God's Word. Please read through the following agreement and initial, sign, and date the form prior to your first appointment. I. Description of Counseling Your counseling will be based on Christian faith. Our aim is to come alongside you and provide wise and loving help by exploring what really matters. Your circumstances matter, so we will seek to understand what you are facing. Your experiences matter, so we will seek to understand how you are living in response to what you are facing. Who God is, what God says, and what God does matter, so we will seek to understand the Hope that he is for us in and through Christ, as revealed in the Bible. We believe deep and lasting change is brought about by God, himself, at the intersection of these things that matter. Our counseling will seek to help you connect the riches of this Hope to the realities of your life. Your counselor has theological and pastoral training and receives regular consultation and continuing education. Our goal is for biblical wisdom to guide the counseling process and content.Initial here if you understand and agree with this Description of Counseling* II. Counseling Goals We see the counseling process as having mutual responsibility. As an equal participant and counselee in the process you have the right to raise questions. Feel free at any time to request an estimate of the predicted length, goals, and desired outcome of the counseling. If you have concerns about the care and counseling you are receiving, you are encouraged to ask your counselor about alternative options. If you have legal, financial, medical or other technical questions, you should seek advice from a professional with expertise in those fields. Initial here if you understand and agree with these counseling goals* III. Fees Calvary Counseling Center is able to operate because of your financial donations. The expenses of Calvary Counseling Center are not underwritten by an individual, church, or corporation. Therefore, it is through the donations of our counselees that the operating expenses of Calvary Counseling Center are met. The comparable-market-value for counseling in the Crawford County area ranges from $75.00 to $125.00 per 50-minute session. Your responsibility is to pray about the amount God would have you donate for the counseling you receive and be faithful to God in your giving. Donations should be in accord with what a man or woman has, not according to what he or she does not have. Therefore, no one will be refused counseling because of the amount of his or her donation. We have made intentional efforts to keep our operating expenses extremely low. However, there are some expenses that are unavoidable. We receive checks, made payable to Calvary Counseling Center, or cash.Initial here is you understand and agree with this Financial Policy* IV. Appointment Cancellation Policy As a non-profit ministry, Calvary Counseling Center must be a careful steward of our resources, including time. Therefore, we ask that you give at least a 24 hour notice for cancellations. If you fail to give us a 24-hour notice we would ask you to provide a $25 donation for your missed appointment.Initial here if you understand and agree with this Cancellation Policy* V. Confidentiality Calvary Counseling Center is very sensitive to the issue of confidentiality. We will carefully guard the information you entrust to us. To release counseling information without your consent would violate both biblical standards and commonly accepted codes of counseling ethics. There are situations, however, where it may be required for us to share certain information with others. Abuse or Neglect: We are committed to protect the vulnerable therefore we will report to appropriate authorities if we believe a minor, elder or person with disabilities to be at risk or that abuse or neglect has taken place. Harm to self or others: We are called to protect life, therefore we will report to appropriate authorities if we believe a person to be at risk of life threatening harm to self or others. Public Health: We live in community and are called to responsible relationship with others, therefore we will participate in the reporting of relevant information to a public health authority when mandated by law and for general health oversight. Legal Requirement: God has instituted authority for the establishment of justice and order, therefore we submit to legitimate requests for information needed for law enforcement purposes and also for the process of legal proceedings. All of our counselors reserve the right to receive consultation with other biblical counselors for the purpose of providing the highest level of care. In these contexts anonymous questions are asked and every effort is made to safeguard the identity of each counselee. Confidentiality is applied by the consultation group as a whole.Initial here if you understand and agree with this Confidentiality Policy* VI. Coordinating Care As biblical counselors we believe that others in the local church body can be helpful in most cases. We encourage you to give permission for your counselor to contact your pastor, elder, deacon, small group leader, or another friend so they can come alongside you in care and encouragement.Initial here if you understand and agree with this Coordinating Care Policy* VII. Help Between Sessions In intensive crises we cannot guarantee that you will quickly reach your counselor. If you face any emergency, please dial 911. If you have an urgent message, call our main number (814-724-8099) between 9 am and 5 pm, Monday - Friday (EST) to speak to someone. We will contact your counselor as soon as possible. You may also email the Director of Calvary Counseling Center at firstname.lastname@example.org.Initial here if you understand and agree with this Help Between Sessions Policy* VIII. Waiver of Liability In seeking counseling from Calvary Counseling Center, you must acknowledge your understanding of the following conditions and further release Calvary Counseling Center, its staff, counselors, employees, Board of Directors, and all organizational leadership, from any legal liability, claim, or litigation arising from your participation in this voluntary program: 1. Counseling will be provided by ordained ministers or biblical counselors who are recognized as having exceptional character and leadership qualities by their church with at least a Master’s degree in counseling. The counseling staff is not a licensed counselor as an LPC (Licensed Professional Counselor), LMFT (Licensed Marriage and Family Therapist), LCSW (Licensed Clinical Social Worker), or LFBPPC (Licensed Fee-Based Practicing Pastoral Counselor) through the state of Pennsylvania; 2. All counseling is provided in accordance with the biblical principles adhered to by Calvary Counseling Center and are not necessarily provided in adherence to any local or national psychological or psychiatric association for the evaluation and treatment of mental disorders and other conditions through the use of a combination of clinical mental health and human development principles, methods, diagnostic procedures, treatment plans, and other psychotherapeutic techniques; 3. No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the above-mentioned counselors, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions; Initial here if you understand and agree with this Waiver of Liability* IX. Resolving Disputes In the case of unresolved differences, you agree to participate in a process of conciliation. This involves: (1) meeting with the Director of Calvary Counseling Center; (2) seeking to settle the dispute by mediation; and, if necessary, (3) settle it by legally binding arbitration. Each of these steps shall be carried out in accordance with the rules and guidelines of the Institute for Christian Conciliation, a division of Peacemaker Ministries.Initial here if you understand and agree with this Resolving Disputes Policy* Personal InformationName* First Name Last Name Date of Birth* MM slash DD slash YYYY Gender* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home TelephoneOK to Leave Voicemail* No Yes Preferred Contact Number* No Yes Cellular TelephoneOK to Leave Voicemail* No Yes Preferred Contact Number* No Yes Work TelephoneOK to Leave Voicemail* No Yes Preferred Contact Number* No Yes Email Address* Education Last Year Completed* Employer* Position* Years* Emergency ContactName* First Name Last Name Telephone*Relationship to You* Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Do we have your permission to contact this person in case of an emergency?* No Yes Marriage & Family RelationshipsMarital Status* Single Steady Dating Engaged Married Separated Divorced Widowed Spouse's Name First Name Last Name Spouse's Date of Birth MM slash DD slash YYYY Spouse's Age Spouse's Employer Position Years Employed Cellular PhoneBusiness PhoneDate of Marriage MM slash DD slash YYYY Length of Time Dating Give a brief statement of circumstances of meeting and datingIs your spouse willing to come to counseling? No Yes Unsure Have either of you been married previously? No Yes Unsure Who was married previously? Me My Spouse Date Married MM slash DD slash YYYY Date Marriage Ended MM slash DD slash YYYY ChildrenIf you have children, please complete the table below:NameAgeGender (M/F)Living (Y/N)Year in SchoolLives at Home (Y/N)Step Child (Y/N)Married (Y/N) ParentsIs your father living? No Yes Unsure If yes, does your father live locally? No Yes Unsure Describe relationship to your father:Is your mother living? No Yes Unsure If yes, does your mother live locally? No Yes Unsure Describe relationship to your mother:Number of Siblings Did you live with anyone other than parents? No Yes If yes, who did you live with? Spiritual/Religious InformationDo you believe in God?* No Yes Unsure Do you pray?* No Yes Would you say you are a Christian?* No Yes Unsure Do you attend a church?* No Yes If yes, what is the name of the church? Are you a member of that church? No Yes If you are a member, what is the pastor's name? Would you be willing to involve someone from your church in the counseling process?* No Yes Unsure Does your family or spouse attend the same church? No Yes What does your community with other believers look like? How has community positively or negatively impacted your life?*How would you describe your religious life?*Have there been any changes in your religious life?* No Yes If yes, how so?* Health InformationDescribe your current health:* Very Good Good Average Poor Do you have any chronic conditions (if so, what?):List important illnesses and injuries or disabilities:Date of Last Medical Exam MM slash DD slash YYYY Results of Last Medical Exam:Physician’s name & address:How many hours of sleep do you average per night?* Is this sleep restful?* No Yes Have you ever used drugs for other than medical purposes?* No Yes If yes, please explain (specific drug(s), amount, frequency, when you stopped, etc.)Do you drink alcoholic beverages?* No Yes How often? How much? Do you smoke?* No Yes How often? Have you tried to stop? No Yes Are you experiencing changes any change or extremes in your emotions or mood?* No Yes If you answered yes, please explain:Have you ever seen a psychiatrist or counselor?* No Yes If yes, please complete the table below:AgeDurationCounselor/PracticeIssues/TopicsHelpful? (Y/N) Are you currently taking medication?* No Yes If yes, please complete the table below:MedicationDosageFrequencyReason PrescribedDate Began Taking Are you willing to sign a release of information form so that your counselor may gather further information or collaborate care with others if it is in your best interest?* No Yes Previous & Current StrugglesCheck any of the following struggles you have experienced or are experiencing at this time:* Abuse, Physical Abuse, Sexual Abuse, Verbal Abuse in the Past Addiction(s) Anger Anxiety Apathy Bad Memories Bitterness Caring for Parents Chronic Pain Codependency Communication, affection Communication, day to day Communication, emotions Communication, planning Communication, problem solving Compulsions Depression Debt Discontentment Divorce Recovery Doubt Salvation Eating Disorder Empty Nest Envy Fear Financial Management Greed Grief Guilt Homosexuality Humility Identity Impatience Infertility Insecurity In-Law Conflicy Jealousy Judgmental Leadership Loneliness Lying Manipulation Marital Intimacy Moodiness Online Sins Panic Attacks Parenting Parenting Adult Child Peer Pressure People Pleasing Perfectionism Pornography Pre-Marital Sex Pride Priorities Procrastination Lack of Purpose Rebellion Rejection Relationships Respecting Authority Respecting Parents Respecting Spouse Same Sex Attraction Self-Control Self-Injury Selfishness Shame Social Anxiety Spiritual Growth Suicidal Thoughts Time Management Work Unfulfilling Other If other, please list: Please briefly describe why you are seeking counseling:*What else you have tried to address this/these issues?*What are your expectations in coming here for counseling?*Any other information that would be helpful for your counselor to know? By signing below, you agree to the following: I have read, understood and agree with the policies contained in this document, I grant permission for Calvary Counseling Center to render counseling services to me, and I also understand that Calvary Counseling Center may terminate services for noncompliance with the plan of care and/or agreed upon administrative issues, failure to keep or cancel appointments, violent behavior, threats of violence, involvement in criminal behavior, or for other similar issues. Enter Your Full Name* Signature*Signature of a parent or guardian is needed if the counselee is a minor or unable to sign for his/her self.Date Signed* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.