Client Intake Form
Please fill out this form to the best of your ability. Your counselor will need this information to prepare for your appointment.
* Required
Email address
*
Your email
Name of Person(s) Requiring Counseling
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Your answer
If the above is a minor, Name of Legal Guardians
Your answer
Which Counselor Are You Wishing to See?
*
Brandy Smith, LPC - General Counseling & Faith-based Counseling
Erin Kincaid - BCBB, MCBB - Biblical-based Counseling
John Sharp - LMFTi - General Counseling & Faith-based Counseling
Sheila Whitney - CLC - Faith-based & General Coaching
How did you learn about Higher Hopes Counseling?
*
Your answer
Email Address
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Your answer
Address
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Your answer
Phone Number
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Your answer
Is it okay to call or text the above number?
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Yes
No
The above is not a cell phone, so calls only please.
Age of person(s) coming to counseling?
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Your answer
Counseling Preparation Questions:
What are the main reasons you feel you or your family member should see someone in counseling?
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Your answer
Higher Hopes Counseling is a faith-based counseling ministry. It is not a requirement that you be a person of faith, but it is a requirement that we notify you that some of our services are faith-based and we are Biblically-focused in our counseling methods. Are your comfortable with Biblical counseling?
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Yes
No, please refer me to a secular counselor.
Have members of your family suffered from the same kinds of thing you have? For example, if you are experiencing depression, did your mother or father struggle with depression? Please explain:
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Your answer
Are you taking any kinds of medications that your counselor needs to be aware of? If yes, please explain. If no, please type no and move to next question.
*
Your answer
Do you use any type of homeopathic remedies such as essential oils, acupuncture, etc.? If so, please explain.
Your answer
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