counseling intake paperwork

1. LIVING WATER COUNSELING CENTER OF SOUTHERN OREGON
A Ministry of Trinity Presbyterian Church & Affiliated with Life Skills International
WHO WE ARE
Living Water is a donation-based, non-profit counseling ministry of Trinity Presbyterian
Church. We are dedicated to Jesus Christ, who is the Living Water, and desire to serve people
in need of counsel. We base our counseling upon the principles of God’s Word, the Bible. We
pray for our counselees, employ our gifts, skills, and training to the best of our ability, and
understand that all is ultimately dependent upon the work of the Holy Spirit.
THINGS TO REMEMBER
1. Because of the number of people requesting counseling, there may be a waiting list. You
will be called on a first come, first serve basis. Be sure to give the receptionist the BEST
number to reach you.
2. All information will be held confidential, with the exception of the counselor determining a
threat of physical harm to you or another person. This type of concern must be dealt with
in a protective manner, possibly involving the authorities who govern these matters in our
state.
3. If child abuse is discovered, the counselee will be advised of the biblical admonitions,
encouraged to do that which is right, and informed that the governing authorities of the
state must be notified.
4. If, during the course of counseling, the counselor discovers or determines that there is
continual unrepentant sin involved in the life of the counselee, or a serious violation of the
civil or criminal law, then appropriate biblical discipline will be followed as outlined in the
scripture, unless otherwise directed by the counselee’s church or by a criminal court of
appropriate jurisdiction. Under these circumstances, Living Water may need to release
information regarding your counseling to others.
OUR FINANCING
We are funded primarily by client donations, and secondarily from individuals, churches, and
other organizations. The ministry can continue only so far as funding is secured through
donations. To this end, the ministry encourages counselees who are unable to donate, to seek
donations from their church’s deacon’s fund or Samaritan’s fund. For those able to support
the continuation of Living Water Counseling ministry, you may refer to the sliding scale for
assistance in determining what the suggested donation would be (see next page for details).
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net

2. SUGGESTED DONATION SLIDING SCALE FOR COUNSELING
(BASED ON FAMILY’S ANNUAL INCOME)
Income Suggested
Donation
$100,000 or more $100/hr
$95,000 $95/hr
$90,000 $90/hr
$85,000 $85/hr
$80,000 $80/hr
$75,000 $75/hr
$70,000 $70/hr
$65,000 $65/hr
$60,000 $60/hr
$55,000 $55/hr
0-$50,000 $50/hr
The suggested donation sliding scale is a guide to help in the decision regarding
how much to donate for every hour of counseling. The minimum donation is $50/hr.
Having read the information regarding Living Water financing, I understand the need for
donations to the ministry when receiving counseling here.
I am able to donate $_____________per HOUR for my counseling. If this amount were to
change due to my ability to pay more or less per session, I agree to notify Living Water at
that time. If I am unable to donate, I will:
_____________ (initial) Pursue help from my church’s benevolence/deacon’s fund
_____________ (initial) Discuss other options with my counselor
INSURANCE BILLING
Because we are a ministry of the church and not licensed by the state because we are a faith
based counseling center, it is uncommon that we will be able to receive payments from your
insurance company, however we are happy to try. Please provide us with your insurance card for
us to photocopy.
Please continue to donate towards counseling until we can ascertain if your insurance company is
willing to work with Living Water Counseling.
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net

3. From past experience we have found it to be more beneficial if you contact your insurance
company personally to let them know that your preference is to use LWC and ask them to work
with us. If you are unsure how to go about speaking with your insurance representative, we’d be
happy to assist with suggestions or to simply provide more information. Thank you.
CLIENT ACCEPTANCE
By accepting counseling from Living Water and its counselors, the counselee agrees to the
following provisions: (please initial each bullet point).
In order to provide ministry in the most effective manner, we ask that you attend all
scheduled appointments, or notify the office staff 24 hours in advance if you must cancel.
There will be a $35 no show fee if you do not notify us 24 hours ahead of your scheduled
appointment time. ___________ (initial)
We believe it is beneficial to both you and your counselor to commit to a minimum of four
sessions, however if after the first session you don’t believe the counselor is the best
person to help you, please let your counselor or the office staff know. We will be more
than glad to schedule another counselor to see you within LWC or recommend a counselor
from another practice to you. ___________ (initial)
Complete all assignments requested by counselor. ___________ (initial)
In some circumstances your counselor may recommend that the session be taped by video
or audio. Please indicate whether you agree to being taped by video or audio for
therapeutic and supervision purposes. ___________ Yes (initial) ___________ No (initial)
**Failure to adhere to the above may result in the counselor terminating the counseling session.
2. In the event of any dispute, charge, claim or other controversy against or involving Living
Water or Trinity Presbyterian Church, or any of its agents, directors, officers, or employees
including the pastor or counselor(s), which in any way pertains to or arises from this counseling
agreement, or counseling which was or could have been rendered at Living Water; such dispute,
charge, claim or controversy, whether on behalf of the counselee or the children named below,
will be first submitted to a panel of five members (three from counselee’s home church leadership
board and two from the officers of Trinity Presbyterian Church). If the counselee has no
designated home church, or if the counselee’s church is Trinity Presbyterian Church, then such
dispute shall be resolved by the elder board of Trinity Presbyterian Church, or its designated
panel of at least three persons. If the resolution by the panel is not satisfactory to either party,
then the dispute, charge, claim, controversy shall be resolved according to the biblical principles
set forth in Matthew 18.
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net

4. PERSONAL DATA
Name__________________________________Ph: (____)_________________Cell: (____)__________________
Today’s Date:__________________________Email__________________________________________________
Address_______________________________________________________________________________________
Occupation____________________________________________________Work Ph: (____)__________________
Years of Education_____________Type of Certification or Degree__________________________________
Sex:  male  female Birth Date __________________________Age____________________
 Single  Engaged  Married  Widowed  Separated  Divorced
If married, how long?______________Spouse’s Name________________________Age__________________
Years of Education ________________Type of Certification or Degree______________________________
Spouse’s Occupation____________________________________________ Work Ph: (____)________________
May we contact you at work? Yes No May we contact your spouse at work? Yes No
If Divorced, Date____________Reason____________________________________________________________
Were you Christian at the time? Yes No
Other pertinent information regarding divorce you would like to share:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Have you ever been separated? Yes No When? From___________ to ______________
Has your spouse ever been divorced? Yes No When?__________________________________
How long was he/she married to previous spouse(s)_____________________________________________
What was the reason for their divorce?__________________________________________________________
Is spouse willing to come for counseling? Yes No
If not, please explain the reason as you understand it___________________________________________
_______________________________________________________________________________________________
Are you a Christian? Yes No Is your spouse a Christian? Yes No
Your denominational preference (if any)________________________________________________________
Are you attending church regularly? Yes No
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net

5. If so, please give name of Church_______________________________________________________________
How long attending? ____________________________ Do you believe in God? Yes No
Who is Jesus to you?___________________________________________________________________________
Does your spouse attend the same Church? Yes No
If not, please give name of his/her Church______________________________________________________
FAMILY DATA
Do you have children? Yes No If so, how many?___________________________________________
Are any of your children step-children? Yes No If so, how many?__________________________
Are any of your children adopted? Yes No If so, how many?_______________________________
Are any of your children foster children? Yes No If so, how many?_________________________
Do any of your children have special needs or physical disabilities? Yes No
If so, please describe briefly____________________________________________________________________
_________________________________________________________________________________________
Have you had any miscarriages? Yes No If so, how many?__________________________________
Have you had any abortions? Yes No If so, how many?_____________________________________
How old were you at the time? _________________________________________________________________
Was your current spouse the father/mother of the child(ren)? Yes No
Please list names, ages, and sex of each of your children:
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Name __________________________ Age ____________________  male  female
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net

6. HEALTH INFORMATION
Status (check one):  Very good  Good  Average  Declining
Other (specify)__________________________________________________________________________
Recent weight changes: Loss ______________lbs. Gain _____________lbs.
Are you presently taking medication? Yes No
If yes, what medication(s)_________________________________________________________________
List all important or critical illnesses you have or had in the past (include injuries or handicaps)
_____________________________ _____________________________ _____________________________
_____________________________ _____________________________ ___________________________
_____________________________ _____________________________ ___________________________
Name of physician____________________________________________Ph: (____) __________________
Have you seen any type of counselor (family, psychologist, psychiatrist, etc). Yes No
If so, please give diagnosis (s)____________________________________________________________
Counselor/Doctor’s Name(s)_____________________________________________________________
Phone Numbers(s)_____________________________________________________________________
Are you willing to sign a release of information for Living Water to obtain medical, social
and/or psychiatric records in order for your counselor to better help you here? Yes No
If no, please explain:___________________________________________________________________
_____________________________________________________________________________________
Have you ever used drugs other than for medical reason? Yes No
If yes, what types(s)____________________________________________________________________
Have you ever had hallucinations? Yes No
If yes, please describe_______________________________________________________________________
Have you ever felt people were watching you? Yes No
How frequent does this occur? _____________________ Is it troubling you today? Yes No
Do you have problems sleeping? Yes No
How many hours per night on average do you sleep? _________________________________________
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net

7. PRESENTING PROBLEM
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PLEASE MAKE SURE THAT YOU HAVE READ ALL PRECEDING PAGES THOROUGHLY, AND
THAT YOU HAVE FILLED OUT OR INITIALED ALL PAGES LEAVING NO BLANKS PRIOR TO
SIGNING THIS AGREEMENT.
I, the undersigned, have read, fully understand, and agree to the above provisions for myself
and/or as guardian for the children named below, if they have contact with the counselor.
_______________________________________________________________ ____________________
Signature Date
___________________________________________________________________ _____________________
Name (please print) Phone No.
___________________________________________________________________ _____________________
Signature of Parent or Guardian Date
___________________________________________________________________ _____________________
Name of Parent or Guardian Name (please print) Phone No.
___________________________________________________________________ _____________________
Name of child or person under guardianship (please print) Date
_______________________________________________________________ _____ ____________________
Name of child or person under guardianship (please print) Date
___________________________________________________________________ ____________________
Name of child or person under guardianship (please print) Date
___________________________________________________________________ ____________________
Witness Signature Date
___________________________________________________________________ ____________________
Witness Name (please print) Date
Medford Location • Trinity Presbyterian Church • 1332 Mt. Pitt Avenue • Medford, OR 97501 • 541-840-1924
Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604
www.livingwatercounseling.net