Service Request Intake Form

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

12/14/2019

Section 2 - Marital Information

Section 3 - Minor Information

Section 4 - Thriving Skills

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

Section 5 - Online Care

Section 6 - Columbia, SC Service

Section 7 - On-Field Service

Section 8 - Spiritual Direction

1 2 3 4 5
Not at all Consistently

Section 9 - 2-Day Debrief

Section 10 - On-Field

1 2 3 4 5
Not at all Very

Section 11 - Check-up

Section 12 - Counseling

1 2 3 4 5
Not very Very

Section 13 - Work Information

Section 14 - Medical Information


 

 

 

Section 15 - Mental/Behavioral Health Information


 

 

 

 

 

Section 16 - Spiritual Information

1 2 3 4 5
Not at all Consistently

Section 17 - Conclusion