Family Ministry: Counseling Intake Form

Thank you for signing up for a counseling session with Zion Church Family Ministry!

To help us best support you, please take a moment to complete the form below. This questionnaire must be submitted before we are able to schedule a session.

Your name *

Email address *

Phone number

Gender

If you are a member/attender of Zion Church, what is your primary campus? *

Marital status *

What do you hope to gain from this session?* *

How long has this been a concern of yours?* *

Is there any additional information that you think may be helpful?* *

Confidentiality Agreement *

In counseling sessions, I understand that I am able to communicate as much as I feel that I need to share with a Family Ministry Team Member of Zion Church. Confidentiality is very important, and by signing below, I agree to hold the Family Ministry Team Member harmless from any claims or liability resulting from disclosure of confidential information to a third party outside of a session by myself or my family members. Family Ministry Team Members WILL KEEP the confidentiality of ALL sessions, EXCEPT in certain situations in which it is required by law to share information during a session.

Including (but not limited to):

If a client is suicidal or threatens to do harm to themselves or others.
When there is a reasonable suspicion of abuse and/or neglect of a child or dependent adult.
When a court of law issues a court order or another legal situation that would require disclosure.

Counseling Understanding *

I understand that the Family Ministry Team Members are NOT licensed counselors and I will not hold Zion Church, its employees or members of the Family Ministry Team responsible for any decisions or actions that I make as a result of our counseling session.

Please Check Below:*

I have read the Counseling Understanding above and I agree.

Electronic Signature *

By signing below, you are signing electronically. You agree that your electronic signature is the legal equivalent of your manual signature. (Please type your full name below as your signature)

Today's Date *

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