Counseling Intake Form

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Background

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Do you feel rested?
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Do you desire to have your religious values incorporated into your counseling?

Please check all that apply:

Feelings
Thoughts
Physical Symptoms
Behavioral Symptoms

Understanding & Agreements

I understand that each session is 50 minutes in length.
I understand that I am responsible for the choices I make and the consequences that follow.
I understand that everything I say is confidential unless my counselor deems me to be a physical threat to myself or another or unless unreported abuse has occurred (as required to report by law).
I understand the fee schedule and will cooperate with our agreement.
I understand that I am to pay by cash, check or card at the beginning of each session.
I understand that I need to call at least 24 hours in advance of my appointment to reschedule or cancel. If I fail to do so, I will pay for the session.
I Understand that Joey Coffman has a MDiv in Pastoral Counseling and Robyn Coffman has Masters in Marriage and Family Therapy. Both are certified under BCPPC (Board of Christian Professional and Pastoral Counselors), and are not licensed by the state of Arizona.
I understand that Joey & Robyn Coffman counsels from a Biblical perspective.
I understand that Joey & Robyn Coffman lease this office space and that The Coffman Company incurs no connection, liability, or responsibility whatsoever.
I understand that brief session notes during or after the session may or may not be taken, but will remain secure and confidential.

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