MARRIAGE & PRE-MARRIAGE COUNSELING FORM Please reach each scope of service parameter by answering the questions below. Our counseling sessions are held during the hours of 9 AM – 3 PM Monday-Thursday and 9 AM – 11 AM on Fridays. Will you be available for appointments during these times?YesNo You Do Not Meet the Requirements Please reach each scope of service parameter by answering the questions below. Click those that apply to you:I have children living in my home who are under the age of 18 from whom I am the primary caregiver (this could be biological children, adopted children, grandchildren, step-children, or foster children)I am a teenager (13-19 years old)We are a young couple who one day hope to have children in our home. You Do Not Meet the Requirements You Meet Our Requirements Please Fill Out the Form Below Date * IDENTIFYING INFORMATION First Name * Middle Initial * Last Name * Date of Birth * Age * Street Address * City * State/Province * ZIP / Postal Code * Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People’s Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d’IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People’s Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe Phone * Email Address * Do we have permission to send text messages and leave voice messages regarding appointments? *YesNo Gender * Race *Select OneAfrican AmericanCaucasianHispanic/Latin AmericanAsian/PacificEast IndianNative American Marital Status *Select OneSingleMarriedDivorcedSeparatedWidowed Prior to today, have you been to our office? *YesNo What services did you receive? *Pregnancy TestParenting ClassesCounselingOther Other: (Please Specify) * How did you hear about us? (Check one of the following): *InternetBillboardRadioChurch/PastorOther Church/Pastor: (Please Specify) * Other: (Please Specify) * Have you ever met with a counselor in the past? *YesNo Who do you live with? * Do you have children at home? *YesNo Briefly tell us why you are seeking counseling. * Are your counseling needs related to drug use or legal issues? *YesNo Please explain * Are you currently experiencing thoughts of hurting yourself or hurting anyone else? *YesNo Please explain * EMERGENCY CONTACT Name * Phone * Relation to Client * EMERGENCY CONTACT Name * Phone * Relation to Client * Date Application Completed * THE RIGHT TO MINISTER We at Wiregrass Hope Group perceive effective ministry as “Life and Hope” overflowing from one person to another. Your helper has been trained in addressing issues of life and sharing hope through the application of biblical truth to daily living and does not necessarily hold a degree in psychology or counseling. Since you have come to him/her for help, it is not considered that he/she has the “right” to minister to you unless you give that right. Giving this right involves responsibility on the part of both the helper and the seeker. The following statements lead to a point of commitment between you, as the seeker, and your helper as to how the healing process may move forward. AREAS OF LIFE: We see human life consisting in several general areas: SPIRITUAL, PHYSICAL, PSYCHOLOGICAL, SOCIAL, FINANCIAL, MARITAL, and PARENTAL. Recognizing that human needs often overlap several of these areas, the helper asks your permission to go into any or all of these areas, to the degree necessary for addressing personal problems. THE FAMILY: We believe marriage is intended to be an exclusive union and lifetime commitment between one biologically born man and one biologically born woman. It is God’s unique gift intended to reveal the union between Christ and His church. We believe God provides for the man and woman in marriage the framework for intimate companionship, the channel of sexual expression according to biblical standards, and the means of procreation of the human race. (Genesis 1:26-28; 2:18-24; Proverbs 14:1; 14:6; 18:22; 31:10-31; Ecclesiastes 9:9; Matthew 19:3-9; Mark 10:6-12; 1 Corinthians 7:1-16; Ephesians 5:21-6:4; Colossians 3:18-21; 1 Timothy 5:14; 1 Peter 3:1-7) DIRECTIVE MINISTRY: While careful listening and empathy are definite aspects of the helping process, this ministry will be directive in nature. This means that direction and assignments will be given based on the teachings and principles of the Bible. While it is not our position that all problems are strictly “spiritual problems”, it is our belief that the vast majority of problems do have a basic spiritual factor. DECISIONS: No decisions will be made for you. You are the one who will decide what you will do with the advice given you. If there is persistence in ignoring the help given, or a refusal to complete assignments, then your helper may raise the question of the advisability of continuing in this helping process. TIME FACTOR: Each helping session lasts from 30 to 90 minutes. There is not a definite minimum or maximum number of sessions required, but you will not be kept coming beyond a reasonable time. If further help is needed in areas where those in other ministries have special expertise, you will be referred to the appropriate ministry. DIFFICULTIES: As you begin to follow Biblical counsel it may happen that your life experience may actually get worse. This is no reason to think that you as a seeker are not making progress. On the contrary, it may be a strong indication that you ARE making progress. In many situations, there is the need for unlearning and undoing certain things so that progress can be made in a new direction. This can initially be painful and discouraging. This is mentioned so that you will not be surprised or disheartened. CONFIDENTIALITY: Your helper is committed to a rule of confidentiality regarding what is discussed in the helping process. Your helper will make every effort to keep private all matters discussed in the helping environment. For the purposes of facilitating the healing process and only with your permission, your helper may record audio of session material using a voice recorder in order to discuss case related material with other helper staff, or with individuals in a supervisory role for training purposes. Audio material is not kept in any archive file but destroyed/deleted after use. In such cases, every effort will be made to conceal client’s identifying information. If you object to audio being recorded during your sessions, please let your helper know. Exceptions to confidentiality may include situations where reasonable suspicion exist concerning abuse, suicidal or homicidal events, or potential harm against yourself, minors (under 18), elderly (over 65), or someone who is disabled. It is required by law for your helper to report such information. LIMITS TO DISTANCE TECHNOLOGY: I understand the limits to distance technology and that I am responsible for confidentiality in my own environment while engaging in any telehealth services with my helper. Although telehealth provides the appearance of anonymity and privacy in counseling, privacy is more of an issue when using technology than in person. By signing below, I am acknowledging the potential risks of confidentiality being breached while engaging in telehealth services through overheard conversations, lack of password protection or leaving information on a public access computer in a library or internet cafe. I understand that while telehealth counseling is a useful tool in addressing mental health issues, it may be necessary to seek counseling in person. Since phone sessions do not allow for a visual representation of my mental health and affect, I understand that distance technology limits the assessment of my mental health. If I share any information that leads my helper to believe that I am in danger of harming myself or other identified persons without giving any other information to explain, I understand that it is likely that my counselor may be obligated to dispatch emergency medical services to my address on file. I understand that telehealth counseling is not a platform for emergency mental healthcare. I release my helper from any responsibility of confidentiality and from any result of my action during a situation of medical emergency. I understand that I should call EMS for immediate assistance during such an emergency. FINANCES: As a ministry rooted in Biblical principles, our finances are guided by: Matthew 10:8 … “freely you have received, freely give”. We would ask you to think on your own application of this principle and to consider a donation to this ministry of $30 to $100 per session. However, we do want to emphasize that help will be given without any consideration of the amount or the frequency of your donation. You will be expected to pay for any recommended books or materials at our cost. All money received will go toward the ongoing support of this ministry. APPOINTMENT POLICY: Providing hope and healing to individuals and families is at the heart of our mission at Wiregrass Hope Group. Because of that, we attempt to keep our schedules at full capacity. We realize that circumstances can arise that necessitate the canceling or changing of appointments, but we do ask that you notify us at least 24 hours in advance in order for us to schedule someone else at that time. If you miss 2 appointments without advanced notice, cancel an appointment without rescheduling, or have not had an appointment in 30 days, you will no longer be considered an active client and may have to be placed on the waiting list if you desire to continue services. Your signature below will signify that you freely accept these principles and understand their importance in the process that you and your helper are undertaking together. Signature Start signing your signature here Your browser does not support e-Signature field. Date * Are you a minor below the age of 18? *YesNo FOR CLIENTS UNDER 18: Legal Guardian Name * Relation to Client * Legal Guardian Email Address * Legal Guardian Phone * Send Message Please do not fill in this field.
