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Crossings Community Church
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LifeCare Ministry - Counseling
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My Commitment to Counseling at Crossings
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1. I understand that the therapy session will last 45-50 minutes.
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I understand that if I am late to the appointment, the session will end at the allotted time.
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Patient Initials
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2. I understand that appointments need to be cancelled 3 business days prior
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to my appointment’s scheduled time so that it can be given to another congregant.
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Patient Initials
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3. I understand that if I have a combination of 3 missed sessions/day of cancels/or late cancels,
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I will be asked to suspend CCC counseling for 3 months.
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Patient Initials
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4. I understand that my worship attendance will be checked periodically.
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And it is my responsibility to complete the Connection Card found in the Worship Folder each time I am in a worship service.
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Patient Initials
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5. I understand that infants, toddlers, children and teens are not allowed at any time in session with me/us.
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As well, children are not allowed in the waiting area before or during my/our hour, even if they are attended by another adult.
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If a minor accompanies me/us, the client(s), that session will be necessarily counted as a ‘missed session’ and rescheduled.
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Patient Initials
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6. I give my permission to receive text and email reminders concerning my appointment information.
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Patient Initials
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Please check here if you are doing marital or couple therapy.
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Marital or Couple Therapy
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1. For marital sessions, both spouses are to be present at session,
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otherwise the session will be rescheduled and count as a “mi
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Patient Initials
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2. Except when scheduling, communication with a therapist for marital therapy must include all 3 parties.
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(You, your spouse, and the therapist.)
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Patient Initials
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Client Intake Form
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Primary phone number for contact and to leave message
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Cell phone number for contact and to sent text reminder
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Email (s)
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2nd
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How were you referred to Crossing LifeCare Ministry
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Reason for seeking counseling
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Duration of those concerns
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Previous attempts to resolve them
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What goals do you have for your treatment?
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On a scale of 1-5, rate your concerns at this point in time
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I am feeling
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Helpless
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Guilty
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Stressed
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Anxious
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Relaxed
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Inferiority Feeling
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Depressed
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Hopeless
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Unhappy
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Out of control
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Happy
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Mood Shifts
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Shameful
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Lonely
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Excessive worry
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Afraid
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Feeling threatened
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Angry
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Sad
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Powerlessness
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Numb
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I am experiencing these thoughts
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Confused
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Unintelligent
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Worthless
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Unmotivated
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Unattractive
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Unlovable
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Confident
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Worthwhile
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Racing
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Obsessive
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Distracted
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Disorganized
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Paranoid
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Sensitive
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Honest
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Suicidal
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Homicidal
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Thoughts of imminent danger
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Hopelessness
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I am experiencing
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Decreased libido
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Increased libido
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Increased risky behavior
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Excessive energy
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Increased irritability
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Crying spelling
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Anxiety attacks
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Avoidance
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Hallucinations
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Unable to join activities
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Inability to sleep
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Excessive sleep
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Loss of interest
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Forgetfulness
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Change in appetite
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Excessive guilt
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Fatigue
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Impulsivity
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Family History
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Relationship History and Current Family
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Current relationship status
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How long
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Partner's name
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Birth Date
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Describe your relationship with your spouse or significant other
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Do you have children?
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If yes, list name(s), age(s), gender(s), and identify whether biological, adoptive, or step children:
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Describe your relationship with your children
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Select all that apply for childhood family experience
• • •
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Family Psychiatric History: Has anyone in your family been diagnosed with or treated for? (Select all that apply)
• • •
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Trauma History
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Do you have a history of being abused emotionally, sexually, physically or by neglect?
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If yes, please describe when, where, and by whom.
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Medical History
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Please list any significant past or current health, medical or psychiatric issues including those resulting in hospitalizations.
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Date
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Problem
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Treatment
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Hospitalized
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Date
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Problem
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Treatment
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Hospitalized
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Date
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Problem
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Treatment
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Hospitalized
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Date
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Problem
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Treatment
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Hospitalized
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Date
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Problem
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Treatment
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Hospitalized
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Date
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Problem
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Treatment
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Hospitalized
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Have you seen or are you currently seeing a psychiatrist, therapist, or counselor?
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Reason
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Therapist
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When
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Helpful
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Reason
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Therapist
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When
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Helpful
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Reason
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Therapist
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When
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Helpful
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Reason
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Therapist
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When
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Helpful
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Reason
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Therapist
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When
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Helpful
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Reason
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Therapist
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When
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Helpful
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Medications
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Current Prescribed Medications
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Doses
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Dates
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Purpose
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Side Effects
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Current Prescribed Medications
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Doses
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Dates
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Purpose
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Side Effects
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Current Prescribed Medications
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Doses
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Dates
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Purpose
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Side Effects
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Current Prescribed Medications
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Doses
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Dates
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Purpose
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Side Effects
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Current Prescribed Medications
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Doses
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Dates
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Purpose
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Side Effects
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Current Prescribed Medications
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Doses
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Dates
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Purpose
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Side Effects
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Current over-the-counter Medications, Vitamins, or Herbs
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Doses
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Dates
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Purpose
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Side Effects
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Current over-the-counter Medications, Vitamins, or Herbs
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Doses
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Dates
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Purpose
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Side Effects
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Current over-the-counter Medications, Vitamins, or Herbs
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Doses
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Dates
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Purpose
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Side Effects
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Current over-the-counter Medications, Vitamins, or Herbs
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Doses
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Dates
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Purpose
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Side Effects
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Current over-the-counter Medications, Vitamins, or Herbs
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Doses
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Dates
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Purpose
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Side Effects
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