Community Counseling Ministry, Inc. Appointment Consent & Questionnaire
Hearts Prepared Community Counseling Ministry, Inc. and those associated with them are not professional or licensed counselors, therapists, medical or psychological practitioners, unless otherwise indicated.  

Ministry sessions are led by trained staff and volunteers deemed to be encouragers in the Christian faith who help people assume their responsibilities as well as resolve personal and spiritual conflicts so that they may experience abundant freedom in Christ.  

All information is strictly confidential and is only for the use of the directors and volunteers of Hearts Prepared Community Counseling Ministry unless prior permission is given.

Encouragers will be legally compelled to break confidentiality if:
A. You are under 18 and are a victim of sexual / physical abuse.
B. We believe you are at risk of harming yourself or others.
C. We believe a child (under the age of 18) or an elder (over age 65) is currently endangered by abuse.

For more information please visit our website at:  www.heartsprepared.com.
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Email *
Name (Last, First): *
Date of birth: *
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Street Address:
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City, State, Zip Code:
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Phone Number:
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Preferred (check all that apply): *
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What are the best days/times for you to meet?  Please include your time zone. 
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How did you hear about us or who referred you?
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I understand that I will not be advised regarding any prescription medication that I am currently taking. This is a matter between myself and my physician.
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I understand and acknowledge that no guarantees are made, nor can be made, with regard to my healing or deliverance and that I am under no financial obligation to receive ministry.  I further state that I have voluntarily sought this ministry for myself.  I hereby release Hearts Prepared Community Counseling Ministry, Inc. and all volunteers from any and all claims of actual or implied liability that may arise now or in the future as a result of the ministry I receive.
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