Pastoral Care Counseling Intake Form

Due to the increased legal complexity surrounding counseling, it is advisable to use a standardized pastoral counseling intake form and not to exceed three sessions of “pastoral care” with any couple or individual before referring out to a licensed practitioner.

Here is a sample form you can customize to your own needs.

GENERAL INFORMATION

• Pastoral Care is a ministry and highly confidential. Support/care generally happens in a series of 45 min sessions, usually ranging in duration of one to three sessions. This form enables initial assessment & consultation. In the first session, you will discuss your presenting issues with the Pastoral Care leader, and together you will determine your best supporting route.
• Client files are the property of our church and will be held in the fullest confidence allowed by law. Situations of child abuse or threat of violence or harm to oneself or others must be disclosed to the appropriate authorities. In some situations, it is also possible for client files to be subpoenaed by the court.
• It is understood that the Pastoral Care leader may consult with peers, counselors or supervisors. Any release of information beyond these conditions will require a separate consent form signed by the client.
• I give CHURCH permission to contact me about this form.
• *Please advise the office 24 hours in advance if you are unable to keep an appointment. A failure to call ahead to cancel your appointment is considered a no-show. Two no-shows could result in file closure. Please print clearly and return this form to the front desk.

SIGNATURE ________________________________ DATE _______________________

PERSONAL INFORMATION

• Name
• Address
• Phone
• Email
• Birthdate
• Marital Status
• Spouse Name / Length of Marriage
• Children Names & Ages

HISTORY

• Church Name / Average Attendance
• Past Counseling / Number of Sessions / Result
• Relevant Medical Information / Doctor / Diagnosed Mental Health Condition / Medications

SPIRITUAL

• I consider myself to be: not a christian, curious about Christianity, a new christian, a baby christian, a growing christian, a mature christian
• I am a follower of Jesus.  I have repented of my sin and given Jesus the complete lead of my life.
• I believe the Bible is the word of God, entirely true, and the source I turn to for what is good.
• I regularly read the Bible and pray

NEEDS

I am looking for pastoral care and biblical counsel for the following situations in my life

• Immediate Family              
• Extended Family
• Parents
• Marriage
• Children
• Life Choices
• Addictions 
• Life Hurts
• Therapy
• Spiritual Growth 
• Biblical Advice
• Other:

SIGNATURE ________________________________ DATE _______________________