Hope for Life Ministry and Counseling Intake Form
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Name
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Address St. City State Zip
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Cell Phone Number
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Home Phone
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Birthday
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Age
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Emergency Contact Name and Phone Number
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Occupation and Employer/School
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Gender
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Married/Single
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How many children and ages?
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Place of worship?
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Physician's name?
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What medication are you taking and amount?
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Why are you seeking counseling?
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How did you hear about us?
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By typing you name below you are agreeing to these terms. I agree to pay $140 per session (:50 min). I understand that Steve will hold all information as confidential except in the case of church discipline. I understand that Steve Leavitt, while having a master in counseling, is not licensed by the state of Texas and does not hold himself out as a professional counselor but as a pastoral biblical counselor.
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A copy of your responses will be emailed to the address you provided.
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