LIVING WATER COUNSELING CENTER OF SOUTHERN OREGONA Ministry of Trinity Presbyterian Church & Affiliated with Life Skills I...
SUGGESTED DONATION SLIDING SCALE FOR COUNSELING(BASED ON FAMILY’S ANNUAL INCOME)Income                    Suggested       ...
From past experience we have found it to be more beneficial if you contact your insurancecompany personally to let them kn...
PERSONAL DATAName__________________________________Ph: (____)_________________Cell: (____)__________________Today’s Date:_...
If so, please give name of Church_______________________________________________________________How long attending? ______...
HEALTH INFORMATIONStatus (check one):  Very good                     Good                        Average          Decl...
PRESENTING PROBLEM________________________________________________________________________________________________________...
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Counseling Intake

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Counseling Intake

  1. 1. LIVING WATER COUNSELING CENTER OF SOUTHERN OREGONA Ministry of Trinity Presbyterian Church & Affiliated with Life Skills InternationalWHO WE ARELiving Water is a donation-based, non-profit counseling ministry of Trinity PresbyterianChurch. We are dedicated to Jesus Christ, who is the Living Water, and desire to serve peoplein need of counsel. We base our counseling upon the principles of God’s Word, the Bible. Wepray for our counselees, employ our gifts, skills, and training to the best of our ability, andunderstand that all is ultimately dependent upon the work of the Holy Spirit.THINGS TO REMEMBER1. 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 FINANCINGWe are funded primarily by client donations, and secondarily from individuals, churches, andother organizations. The ministry can continue only so far as funding is secured throughdonations. To this end, the ministry encourages counselees who are unable to donate, to seekdonations from their church’s deacon’s fund or Samaritan’s fund. For those able to supportthe continuation of Living Water Counseling ministry, you may refer to the sliding scale forassistance 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 • 541-840-1924Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604 www.livingwatercounseling.net
  2. 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/hr0-$50,000 $50/hrThe suggested donation sliding scale is a guide to help in the decision regardinghow 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 fordonations to the ministry when receiving counseling here.I am able to donate $_____________per HOUR for my counseling. If this amount were tochange due to my ability to pay more or less per session, I agree to notify Living Water atthat 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 counselorINSURANCE BILLINGBecause we are a ministry of the church and not licensed by the state because we are a faithbased counseling center, it is uncommon that we will be able to receive payments from yourinsurance company, however we are happy to try. Please provide us with your insurance card forus to photocopy.Please continue to donate towards counseling until we can ascertain if your insurance company iswilling 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. 3. From past experience we have found it to be more beneficial if you contact your insurancecompany personally to let them know that your preference is to use LWC and ask them to workwith us. If you are unsure how to go about speaking with your insurance representative, we’d behappy to assist with suggestions or to simply provide more information. Thank you.CLIENT ACCEPTANCEBy accepting counseling from Living Water and its counselors, the counselee agrees to thefollowing 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 LivingWater or Trinity Presbyterian Church, or any of its agents, directors, officers, or employeesincluding the pastor or counselor(s), which in any way pertains to or arises from this counselingagreement, 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 leadershipboard and two from the officers of Trinity Presbyterian Church). If the counselee has nodesignated home church, or if the counselee’s church is Trinity Presbyterian Church, then suchdispute shall be resolved by the elder board of Trinity Presbyterian Church, or its designatedpanel 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 principlesset 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. 4. PERSONAL DATAName__________________________________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  DivorcedIf 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 NoIf Divorced, Date____________Reason____________________________________________________________Were you Christian at the time? Yes NoOther 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 NoIf not, please explain the reason as you understand it__________________________________________________________________________________________________________________________________________Are you a Christian? Yes No Is your spouse a Christian? Yes NoYour 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. 5. If so, please give name of Church_______________________________________________________________How long attending? ____________________________ Do you believe in God? Yes NoWho is Jesus to you?___________________________________________________________________________Does your spouse attend the same Church? Yes NoIf not, please give name of his/her Church______________________________________________________FAMILY DATADo 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 NoIf 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 NoPlease list names, ages, and sex of each of your children:Name __________________________ Age ____________________  male  femaleName __________________________ Age ____________________  male  femaleName __________________________ Age ____________________  male  femaleName __________________________ Age ____________________  male  femaleName __________________________ Age ____________________  male  femaleName __________________________ Age ____________________  male  femaleName __________________________ Age ____________________  male  femaleName __________________________ 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. 6. HEALTH INFORMATIONStatus (check one):  Very good  Good  Average  DecliningOther (specify)__________________________________________________________________________Recent weight changes: Loss ______________lbs. Gain _____________lbs.Are you presently taking medication? Yes NoIf 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. 7. PRESENTING PROBLEM______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASE MAKE SURE THAT YOU HAVE READ ALL PRECEDING PAGES THOROUGHLY, ANDTHAT YOU HAVE FILLED OUT OR INITIALED ALL PAGES LEAVING NO BLANKS PRIOR TOSIGNING THIS AGREEMENT.I, the undersigned, have read, fully understand, and agree to the above provisions for myselfand/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 • 541-840-1924Grants Pass Counseling Location • The Guild Building • 1867 Williams Hwy • Grants Pass, OR 97527 • 541-244-2604 www.livingwatercounseling.net

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