All information is confidential and will not be shared with anyone except the counselor you are paired with.

Name:  

Address:   
Address2: 
City:          State:    Zip:       County of Residence:

Preferred City of Counseling: (If you prefer counseling closer to your employment or school)      

Phone #1:      E-mail:

Please list only a phone number and/or e-mail address that we can leave a message if needed.

Type of Counseling you are seeking?   Individual          Marital/Family

Gender (M/F):       Ethnicity :

(This data is ONLY collected for data collection that is essential for us to secure future funding and ensure we are serving a diverse community.)
Age Range (select one): 18 - 25     26 - 35     36 - 45     46 - 55     56 - 65     66 - 75     76 - 85     86+

FAMILY DEMOGRAPHICS

Marital Status (select one): Single    Married    Separated    Divorced    Widowed    Significant Other

Number of people in your household:       How many are under 18 years old:

Annual Gross Household Income: including all deductions for taxes, retirement, and insurance
Other Income:      Child Support:               Alimony:
                            Disability:                      Retirement:
                            Public Assistance:          Other:   

If you are seeking marital or family counseling please complete the spouse information:

Spouse's Name:
Spouse's Address (if different):
Spouse's Employment:

Your Employment and/or School: Employment   Attending School:

Your Church Affiliation (if any):   Pastor's Name:

Your Pastor will not be contacted - this information is for internal use of the clients we are serving.

Your preference (if any) for: Male or     Female Pastoral Counselor
I have already contacted a Partnership Counselor (please fill in their name):

PRE-EVALUATION QUESTIONAIRE

What is the difficulty that caused you to seek counseling?

Please rate your present level of distress: (1=Very distressed; 10= No distress)
1      2      3      4      5      6      7      8      9      10
                                                                                                                 

Please rate your present ability to cope with the difficulty you are experiencing:

(1=Very stressed with little ability to cope; 10=Not stressed about situation and coping very well)
1      2      3      4      5      6      7      8      9      10
                                                                                                              

Please rate your overall life satisfaction:
1      2      3      4      5      6      7      8      9      10
(Low)                                                                                                                     (High)

How important is it to you that your counselor takes seriously your religious faith perspective?
1      2      3      4      5      6      7      8      9      10
(Not Important)                                                                                            (Very Important)

Please list any insurance available. The Partnership can provide assistance to insured individuals, families or couples that have high deductible and/or high co-payments or health coverage that does not cover mental health.  We do not have the ability to contact your insurance carrier to verify benefits available.  

Please contact your insurance company to find out mental health benefits available prior to submission of your application.

Name of Insurance Company:
Policyholder (circle one): Self       Spouse       Parent       Name of Policyholder:
Policy #: Group Policy #:
Deductible for Mental Health Benefits:      Session Co-Payment:
Does your insurance cover pastoral counseling? Yes       No

How did you hear of us?

Do you have special requirements for scheduling time?:

Are you currently under the care of another counselor? 

If yes, please explain reason you are seeking counseling through the Partnership under special circumstances box below.

Are there any special circumstances you wish to make us aware of?

You will be sent a letter regarding the status of your application to the above address unless otherwise noted. During your counseling the Executive Director will confidentially know your identity. Do you understand and agree to this arrangement?
Yes       No

I have read and understand the Client Guidelines. Yes      No 

The Partnership for Pastoral Counseling has the right to deny and/or terminate services of any applicant providing misleading information or

that does not adhere to the client guidelines upon approval of application.