New Client Intake Form

New Client Intake Form - Roxanne Maroney

Pastoral Counseling and Couple’s Coaching

I am certified as a Biblical Counselor through AACC, the American Academy of Christian Counselors and my background and training in Pastoral Counseling comes from the School of Spiritual Direction through New Way Ministries. My approach is integrating Biblical principles and the love of God along with healthy tools for better relationships. My Couple’s Coaching is based on many years of experience working with individuals and couples, integrating principles through the Gottman Institute level one training as well as Attachment theory. I have been married 47 years and have lived out the principles and advice I offer. I am not a licensed psychotherapist or mental health professional; therefore I will give referrals to those areas of expertise if I believe an individual’s problems lay outside the scope of my specialty or abilities.

Goals and Objectives of Pastoral Counseling and Couples Coaching

The primary goal of any pastoral counseling or couples coaching is to increase your understanding of yourself, your partner, and the patterns of interactions that have become detrimental to the relationship. Once these have been explored and understood, we explore how to change thoughts, feelings and actions that are ineffective or destructive. The essential skills needed to engage in successful couples coaching are:

"*" indicates required fields

Are you responding as an individual or a couple?*

*** If replying as a couple, both partners please complete a form ***

Basic Information

Name*

First Last

Date of Birth*

Email*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Relationship Information

Marital Status*

Spouse Name*

First Last

How long have you been married?*

How long have you been separated?*

How long have you been divorced?*

How long have you been widowed?*

If prior marriages please describe:

Do you have any children?*

Yes

Names and Ages of Children*

Family History Background

Father's Name*

First Last

Still living?*

Age if Living

Mother's Name*

First Last

Still living?*

Age if Living

Do you have any siblings?*

Names & Ages of Brothers & Sisters*

Please include yourself, and any half brothers and sisters names

Health Information

How Would You Rate Your Health?*

Are you on medications?*

If yes, please list:*

Have you had a history of addiction or has there been addiction in your family?*

If yes, please describe:*

Do you have any history of trauma (physical, sexual, emotional)?*

If yes, please describe:*

Counseling Information

What causes you to reach out to me at this time?*

What have you done about your concern up to this point?*

Is there any other information you think I should know? Please describe.*

Emergency Contact (Name; Phone; Relationship):

Signature: I have read and fully understand this agreement and the stated policies mentioned below.*

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Additional Couples Coaching Information

Appointments and Cancelations

A standard appointment time is 55 minutes in length. Your appointment time is reserved for you. It is your responsibility to notify me at least 24 hours in advance if you are unable to attend. Cancellations with less than 24 hours notice will be charged at 50% of the rate for the session.

Emergency Calls

You may call me at 949-632-1796 at any time and if I am not available you will be forwarded to my private voice mail. I will return your call promptly when I pick up messages. In the event of any life-threatening emergency it is important to seek help immediately by going to the hospital or dialing 911.

Fees

The agreed upon fee for each session will be $75.00 per 55 minute session for individuals and $120.00 for couples. On occasion, at the discretion of the coach, the session may be extended at no additional cost. A receipt may be provided to the client upon request; however, pastoral counseling and coaching typically does not qualify for insurance reimbursement.

Confidentiality in Couples and Family Coaching

Couples and family coaching may include both joint and individual sessions. In such circumstances the couple or family agrees to waive their right to confidentiality so that information shared in individual sessions may be shared in joint session, at the discretion of the counselor, to maintain an atmosphere of openness and honesty.

Agreement

I acknowledge that I have read, fully understand, and agree to these stated policies.

Confidentiality

The material you disclose is confidential and cannot be released without your written consent. There are certain circumstances, however, under which I may be legally required to disclose information. These include:

If there is reasonable belief or suspicion that child abuse has occurred.
If there is reasonable belief or suspicion that elder abuse or dependent adult abuse has occurred.
If you make a threat to harm another person.
If you pose a risk to yourself or others.
If you enter into a legal proceeding in which you raise the issue of your mental status, then the court may order your records.

From time to time, I may want to consult with a licensed therapist regarding our sessions. You will be made aware of these consultations and your confidentiality will be protected. Consultation and supervision are inherent in the standard of care and are supported by the pastoral counseling and coaching profession.

Work Agreement

It is agreed that the client shall make a good-faith effort at personal growth and engage in the coaching process as an important priority at this time in his or her life (lives).

Termination

Clients may terminate this counseling agreement at any time for any reason subject to the payment provisions above. The pastoral counselor may also terminate the agreement on any grounds through oral or written communication.