Intake Form - GRC Service Portal

The information you share here is secure and confidential.
If you are seeking couples counseling, please have your spouse also complete this form individually.
If you are completing this Intake Form for your child, please fill it out with their information and from their perspective.

Section 1 - Your Information

Date

12/14/2019

Title

Last Name

First or Preferred Name

Date of Birth

Phone

Emergency Contact Name

Emergency Contact Email

Emergency Contact Phone

Sending Organization

How many years have you served cross-culturally?

Country of Service

Where are you currently located (Country or state if in the US)

How did you hear about GRC?

Birth Nationality?

Current Marital Status

Section 2 - Marital Information

Spouse's Last Name

Spouse's First or Preferred Name

Spouse's Email

Spouse's Phone

Spouse's Birth Nationality?

Please list any children (Name, age, gender)

Go to Section 4

Section 3 - Minor Information

Father's Last Name

Father's First Name

Mother's Last Name

Mother's First Name

Father's Email

Mother's Email

Primary Contact regarding the minor client's care

Section 4 - Thriving Skills

Please rate the degree you are thriving in each area
(1 - Severely Struggling; 5 - Thriving)

	N/A	1	2	3	4	5
Identity
Marriage
Parenting
Friends
Team
Nationals
Extended Family
Spirituality
Emotional Health
Physical Health
Sexuality
Transition

Where would you like to receive help?

Section 5 - Online Care

Which service would you like to receive?

Section 6 - Columbia, SC Service

Which service would you like to receive?

Section 7 - On-Field Service

Which service would you like to receive?

Section 8 - Spiritual Direction

How would you describe your spiritual journey over the last year?

Please describe any regular spiritual rhythms or spiritual disciplines that you practice

To what degree do you practice a weekly sabbath?

	1	2	3	4	5
Not at all						Consistently

How have you sensed God's work or His presence in your life in the last few months?

How do you sense God is leading you in this present season?

What are your desired outcomes for spiritual direction?

Go to Section 16

Section 9 - 2-Day Debrief

Who will be joining you for this debrief?

If applicable, please list name, gender, and age of all others attending the debrief with you.

What period of time would you like to debrief? (Past term; last year; since a particular event; etc.)

Please describe any pertinent experiences or circumstances that led you to seek debriefing.

What areas/topics do you want to be sure to cover during your debrief?

Go to Section 16

Section 10 - On-Field

What is your primary concern?

How severe is your concern?

	1	2	3	4	5
Not at all						Very

What do you hope to accomplish from your time with your Provider?

Go to Section 16

Section 11 - Check-up

What areas of life would you like to address in your time with your Provider?

What do you hope to take away from your time with your Provider?

Go to Section 16

Section 12 - Counseling

What is your primary concern?

Please describe when and how your concern began.

The severity level of your concern

	1	2	3	4	5
Not very						Very

What have you already tried to do about this concern?

What are your goals for counseling?

Section 13 - Work Information

What is your current role?

Education Completed

Section 14 - Medical Information

List any significant present or past medical conditions, illnesses, injuries, or handicaps.

On average, how many hours of sleep do you get per night?

Have you had any recent changes in sleeping patterns?
Yes No

If so, please explain.

Please list any significant food allergies.

Have you had any recent changes in weight (gain or loss)?
Yes No

If so, please describe.

Please list all medications currently or recently taken. (including prescription and over-the-counter and all natural/herbal/vitamin supplements)

Please list any allergies to medications.

Have you ever used drugs other than for legal medical purposes? (current or past)
Yes No

If so, please describe what you used, frequency, and how long ago.

Section 16 - Spiritual Information

Please describe your use of spiritual disciplines/practices.

To what degree do you practice a weekly sabbath?

	1	2	3	4	5
Not at all						Consistently

Please describe any relevant spiritual experiences, either positive or negative, in the last couple of years.

Section 17 - Conclusion

When do you hope to begin? Please include possible dates and times. Please let us know your sending organization if it was indicated as 'Other' previously.

Please share anything else that you would like your Provider to know before your first session.

We would appreciate any feedback you can give about this Intake Form that would help us better serve future clients.

Service Request Intake Form

Section 1 - Your Information

Section 2 - Marital Information

Section 3 - Minor Information

Section 4 - Thriving Skills

Section 5 - Online Care

Section 6 - Columbia, SC Service

Section 7 - On-Field Service

Section 8 - Spiritual Direction

Section 9 - 2-Day Debrief

Section 10 - On-Field

Section 11 - Check-up

Section 12 - Counseling

Section 13 - Work Information

Section 14 - Medical Information

Section 15 - Mental/Behavioral Health Information

Section 16 - Spiritual Information

Section 17 - Conclusion