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 follows standard ethical guidelines for privacy and confidentiality. However, certain situations require disclosure without consent, as permitted or required by law. If there is concern that the appointee may be a danger to themselves or others, or if there is suspected abuse of a minor, information may be shared with appropriate mental health professionals 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

Please provide at least 24 hours’ notice if you need to cancel so the time can be offered to others. Missed appointments without notice will be recorded as a no-show. Two no-shows within 12 months may result in denial of future appointments.

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 by drugs or alcohol. Sessions will end immediately if aggressive behavior—verbal or physical—is displayed toward the pastoral counselor.

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

YES

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

YES