Client Intake Form & Registration
Please fill out this form to the best of your ability. This form is for counseling AND class/group registration. Your counselor/facilitator will need this information to prepare for your appointment.
Email address *
Name of Person(s) Requiring Counseling *
If the above is a minor, Name of Legal Guardians
Which Counselor Are You Wishing to See? *
How did you learn about Higher Hopes Counseling? *
Are you an American Legion referral? *
Email Address *
Address *
Phone Number *
Is it okay to call or text the above number? *
Date of person(s) receiving services? *
Counseling Preparation Questions:
The following question help our team to prepare for your intake call (if required) and service. Please fill out to the best of your ability.
What are the main reasons you feel you or your family member should see someone in counseling?
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. Do you understand that we are a faith-based organization? *
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:
Are you taking any kind of medication that your counselor needs to be aware of? If yes, please explain. If no, please move to the next question.
Do you use any type of homeopathic remedies such as essential oils, acupuncture, etc.? If so, please explain.
What is your religious affiliation, if any? This question is asked only to pair you with the best counselor for your religious background, iff applicable. Religious background is not a mandate for counseling.
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