Pastoral Counseling Intake Form

Take your next step to healing and moving toward peace in your life with Pastoral Counseling. We're proud of you for doing the work. Here's what you need to do: complete and submit this quick intake form. Once submitted, we will reach out to you and get your appointment scheduled.

*Pastoral counseling is only scheduled one appointment at a time.

For questions please contact: Counseling@Medwaychurch.org

Your name *

Email address *

Address *

Phone number *

Do you currently attend Medway Church? *

Gender *

Are you over 18 years old? *

Yes

Your Occupation: *

Employer Name:

Marital status *

This appointment is for: *

Have you ever participated in counseling before? *

Briefly describe what brings you to pastoral counseling. *

What do you hope to receive from pastoral counseling? *

Describe your current use of drugs/and or alcohol. *

Confidentiality Promise

Your pastoral counselor will adhere to commonly accepted codes of privacy and confidentiality in counseling ethics. There are situations, however, in which the law requires that certain information can be revealed without your consent. Under the discretion of the pastoral counselor, if there is any indication that you may be a danger to yourself or others, or are involved in the abuse of a minor, your information may be disclosed to appropriate mental health services or law enforcement.

What is Pastoral Counseling?

Pastoral counseling is talk therapy that combines empathy, applicable practices, and your faith in Jesus as a way to provide clarity, healing and hope for the difficult things in life.

We are not professional counselors or licensed therapists. Our lay counselors have been trained to help with a variety of personal and spiritual issues.

Cancellation Policy

We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours notice. This will enable another person who is waiting for an appointment to be scheduled in that appointment slot. Those who do not show up for their appointment without notification will be considered as a NO SHOW. People who No-Show two (2) or more times in a 12 month period, may be denied any future appointments. Our office firmly believes that a good helping relationship is based upon understanding and good communication.
Questions about cancellation and no show policy should be directed to counseling@medwaychurch.org.

Childcare

Childcare is not provided during counseling sessions and children cannot be left unattended.

Code of Conduct

Appointments will be canceled if the appointee arrives impaired due to drugs or alcohol. An appointment will also be ended immediately if the appointee exhibits aggressive behavior in speech or action towards their pastoral counselor.

I understand the policies of the Pastoral Counseling Ministry and agree to abide by them. *

(For questions regarding this please email: counseling@medwaychurch.org)

YES

I understand this is a Pastoral Counseling with a lay counselor, not professional or licensed care. *

(For questions regarding this please email: counseling@medwaychurch.org)

YES

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