Client forms

Coaching Intake & Informed Consent

Please complete this before your first session. It takes about ten minutes.

Before we begin

A few things to know

If any question is uncomfortable, leave it blank. We can talk about it in person. Fields are required unless marked optional.

Coming as a couple? Each of you needs to complete your own intake and consent form.

What you enter here is used only to build your signed agreement. The finished document is stored in Restoration Soul Care's private files, and a copy is emailed to you only if you ask for one at the end.

If you are in immediate danger, call 911. If you are struggling and need to talk to someone right now, call or text 988, the Suicide & Crisis Lifeline, available 24 hours a day. Please do not wait for your appointment.

Part 1 · Client intake

Your information

Full name

Please enter your full name.

Date of birth

Please enter your date of birth.

Parent or guardian

Because the client is under 18, a parent or legal guardian needs to complete and sign this form with them.

Parent or guardian full name

Please enter the parent or guardian's name.

Relationship to client

Please enter the relationship.

Parent or guardian phone

Please enter a phone number.

Parent or guardian email

Please enter a valid email address.

Street address optional

City / State optional

ZIP optional

Phone

Please enter a phone number.

Please enter a valid email address. Your signed copy will be sent here.

Preferred method of contact

Phone call Text message Email

Please choose one.

May we leave a voicemail or send a message that identifies Restoration Soul Care by name?

Yes No, please leave name and number only

Please choose one.

Please complete the highlighted fields.

Part 1 · Client intake

Emergency contact

Someone we may contact if we have serious concern for your safety.

Name

Please name an emergency contact.

Relationship

Phone

Please enter their phone number.

How you found us

Podcast Website Referral from a person Church or ministry Social media Other

Tell us more optional

Please complete the highlighted fields.

Part 1 · Client intake

What brings you here

In your own words, what are you hoping to work on?

What would a good outcome look like six months from now?

Part 1 · Client intake

Current care and support

Are you currently working with a therapist, counselor, psychiatrist, or other licensed mental health professional?

Yes No

Their name and contact

Would you be willing to sign a release so that I can coordinate with them? Coordination is often helpful, and is always your choice.

Yes No I'd like to discuss it first

Have you received mental health treatment or counseling in the past?

Yes No Prefer not to say

Are you currently prescribed medication by a physician or psychiatrist for mental health or emotional concerns? You do not need to list the medication.

Yes No Prefer not to say

Do you have any current concerns about your use of alcohol or other substances?

Yes No Unsure

Are you currently having thoughts of harming yourself or another person?

Yes No I'd like to talk about this in person

Yes No

If yes, briefly

Anything else

Is there anything else you would want me to know before we begin? optional

Part 2 · Agreement & informed consent

Acknowledgment and signature

By signing, I confirm that:

Acknowledgments. Check each statement.

Please check each statement to continue.

Your signature

Printed name

Please enter your name as it should appear on the agreement.

Sign below

Sign here with your finger, stylus, or mouse

Please sign above, by drawing or typing your name.

Date and time will be recorded automatically when you sign:

Please complete the highlighted items above.

All done

Thank you, .

Your intake and signed agreement are complete. Download a copy for your records below.

Preparing your document…

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Send a copy to

PO Box 154, Goshen, KY 40026 · info@rscky.com