PLEASE NOTE: This form is used to determine if Christian, pastoral counseling is suitable for your situation. All sections contain required information, so please complete each section, then click next to move to the next section.

Step 1 of 6

Personal Information
Is the individual seeking counseling an Adult or Minor?*
Your Name:*
First Last
Contact Number:*
E-Mail Address:*
Parent / Guardian Name:
First Last
Parent / Guardian Contact Number:
Parent / Guardian E-Mail Address:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth:*
MM slash DD slash YYYY
Are you Employed?*
What is your Occupation?*
Name of Employer:

Family Information
Marital Status:*
Do you have Children?*

What are your children's names and ages?*

First Name:	Last Name:	Age:

Church Involvement
What service do you attend at Cascade Hills?*
Have you attended one of our Starting Point events?*
Are you currently attending a Small Group / LIFEgroup / Cascade U Class?*
What is the name of the group / class you're attending?*
Are you currently serving in a ministry?*
In what area(s) of ministry are you serving in?*
Who referred you to Cascade Hills Church for counseling?*

Emergency Contact
Emergency Contact Name:*
First Last
Phone Number:*
What is your Emergency Contact's relationship to you?*

Counseling Needs
Briefly describe why you are seeking pastoral counseling:*
Are you currently having suicidal thoughts?*
Has a physician diagnosed you with depression?*
Have you ever been diagnosed with borderline personality disorder?*
When were you diagnosed with borderline personality disorder?*
MM slash DD slash YYYY
Have you ever been diagnosed with bipolar disorder by a physician?*
When were you diagnosed with bipolar disorder?*
MM slash DD slash YYYY
Have you ever been hospitalized for psychiatric/alcohol/drug treatment?*
When were you hospitalized for psychiatric/alcohol/drug treatment?*
MM slash DD slash YYYY
Have you been to Cascade Hills Church for Pastoral Counseling before?*
When did you last attend Pastoral Counseling at Cascade Hills Church?*
MM slash DD slash YYYY
Who is your family / personal care physician?
First Last
Contact Number for Physician:

Please list any medications you are currently taking:

Click the + icon to the right of the input field to add additional medications.

Counseling Consent Form
Christian Pastoral Counseling

Cascade Hills Church is fully committed to serving and providing our clients with the highest quality biblical, Christian, pastoral counseling available. Our services are provided to members of Cascade Hills Church free of charge.

Christian counseling is covered under clergy confidentiality; therefore, any information discussed in counseling is not available for subpoena in any court of law. In addition, the client understands that any notes or files on the client are the sole property of Cascade Hills Church and are not to be removed or given to anyone, including the client. If the client is involved in a legal dispute or if it is perceived that a potential legal issue may arise, it is the discretion of the counselor to refer the client to a licensed professional counselor at any time.

Counseling is provided by non-licensed Christian Counselors who are seminary-trained to deal with spiritual concerns. If any in-depth psychological counseling is necessary, clients will be referred to a licensed professional counselor.

The nature of counseling requires the expectation that all conversations with the counselor are kept confidential and that under no circumstances is that information disseminated, except for reasons of peer supervision or when the client or another individual is in danger or at risk.

Premarital counseling consists of 6 fifty-five minute sessions and is a requirement to get married at Cascade Hills Church or by any of our ministers. The client understands that outside of the counseling-client relationship, there may be situations which arise when the client may interact with the counselor. At no point, the counselors will not discuss any counseling related issues, to ensure the client’s confidentiality.

Appointment Information

Due to limited sessions, if a client fails to show for an appointment without giving proper advanced notice, the client could be suspended from counseling services for an extended time. If it happens more than once, the client will be referred to another counseling center. To make or cancel an appointment, please call 706-327-5743.

If a client arrives late for an appointment, they will only receive counseling for the remainder of the allotted session time. Client sessions will only last 55 minutes and cannot be extended due to tardiness.

Childcare issues arise periodically. We cannot provide childcare during appointments nor can children be present in sessions in most cases.

I have read this agreement for counseling consent form and by signing, I am complying with all the stated requirements for Christian pastoral counseling at Cascade Hills Church. I also agree that I cannot call any Cascade Hills Church pastoral counselor to testify on my behalf or on the behalf of my children/family members in a court of law.
Electronic Signature:*
By signing your full name here, you agree to the terms provided in the above consent form.
Today's Date:*
MM slash DD slash YYYY
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Service Information

Step 1 of 6

Personal Information

Family Information

Church Involvement

Emergency Contact

Counseling Needs

Counseling Consent Form

Christian Pastoral Counseling

Appointment Information