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.
* Required
Email address
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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?
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Brandy Smith - General Counseling, Couples & Faith-based Counseling
Erin Kincaid - Biblical-based Counseling, Pastoral & Missions Member Care
John Sharp - General Counseling,Couples & Faith-based Counseling
Sheila Whitney - Faith-based, Business & Life, Adult ADD/ADHD Coaching
Michelle Rives - Biblical, Women, Teens, Grief & Loss Counseling
Sara Jones - General & Faith-based, Couples, Teens, Family Counseling
I am registering my teen for the Virtual Teen Group Counseling on Wednesdays 4:30 - 5:45p
Anger Management Class -Women's Tuesdays 7-8:30pm Class - Virtual
Anger Management Class -Men's Thursdays 7-8:30pm Class - Virtual
Anger Management Class - Co-Ed Thursday - 12-1:15pm Class - Virtual
Veterans Support & Counseling Group - Tuesdays - 7-8:15pm - Virtual
I am not sure who I need to see, please contact me.
How did you learn about Higher Hopes Counseling?
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Your answer
Are you an American Legion referral?
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Yes
No
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.
Date of person(s) receiving services?
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Your answer
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?
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. Do you understand that we are a faith-based organization?
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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:
Your answer
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.
Your answer
Do you use any type of homeopathic remedies such as essential oils, acupuncture, etc.? If so, please explain.
Your answer
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.
Your answer
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