Welcome to the Bread of Life Counseling Center 13724 HWY 53 Marble Hill, GA 30148
706-692-7960 Instructions for Completing Submitting Intake Form
Please confirm our availability to your situation at 706-692-7960. After you have done so complete and sign our intake form (available on Bread of Life website or at the Bread of Life Counseling Center office). Please complete and submit the entire intake form without removing any pages. Intake forms done on line will go directly to the Director and will be kept in strictest confidence. If arranged with the Director beforehand you may be allowed to fill out your intake form in person at the counseling center offices.
Two additional options are available for completing the intake form.
1. You may mail print out the intake form and mail. Click hereto download the form.
(Keep pages 1 & 2 for your information. PLEASE SUBMIT ALL OF PAGES 3-8.)
Please mark the envelope as “CONFIDENTIAL” and mail to:
BREAD OF LIFE COUNSELING CENTER 13724 HWY 53 Marble Hill, GA 30148
2. You may complete the form online. See questions below and click Submit when you are finished.
Once your form is received we will begin the process of scheduling. If there is a waiting list, scheduling will be dealt with on a first come-first served basis or as dictated by need. On the last page of this form there is a box for you to indicate what appointment times are best for you. Please offer as much flexibility as possible and we will attempt to accommodate these times if our schedule allows.
Blessings, Garry Barber, Director
What is Expected of You?
It is our belief that change must begin with ourselves as we look to Christ for the power to change. Therefore, we ask you to approach the counseling and encouragement process as an opportunity for personal change and spiritual growth. We ask that you refrain from the temptation of focusing on others, and instead we ask you to focus on what changes God desires to make in your life, in the midst of your circumstances.
Be advised that you may be assigned “homework.” Homework is a vital part of the change process; therefore, completion of the homework assignments before your next session is expected.
Availability
Our ministry, at times, may carry a waiting list. If our waiting list is prohibitive, we will offer outside referral options.
Our ministry is available on an appointment basis only. Each session will typically last 50-60 minutes. If you need to reschedule or cancel an appointment, we ask that you call at least 24 hours in advance. This allows us to reschedule others who are on our waiting list. Repeated failure to keep appointments or give proper notice of cancellation may result in termination of sessions.
Confidentiality
The information you share with your professional counselor will be carefully guarded and ethically cannot be disclosed without your written consent, with the following exceptions:
1) It is required by Georgia law that all counselors have a duty to warn the appropriate individuals if the counselee intends to take harmful, dangerous, or criminal actions against themselves or someone around them. Professional counselors are also mandated to report any incidences of “reasonable suspected child abuse” (physical or sexual), elder abuse, or suicide attempts.
2) We reserve the right to consult with other counseling professionals or appropriate church ministry staff members regarding your sessions. This consultation will be held in the same level of confidence as your sessions.
Resolution of Disagreements
If a dispute should arise between the person receiving ministry and the counselor regarding the session or the counselor’s advice or conduct, one should bring this dispute to the attention of the Director of the Bread of Life ministry. If the dispute cannot be resolved at this level, all parties agree to resolve such dispute by submitting to the Bread of Life Counseling Center Board of Directors for full and final resolution and conciliation.
Waiver of Liability
The undersigned, having sought biblical counseling as such as adhered to by the Bread of Life Counseling Center, a nonprofit religious organization, hereby acknowledges their understanding of the following conditions and further releases from liability the Bread of Life Counseling Center and participating churches, pastors, agents or employees, from a claim or litigation whatsoever arising from the undersigned’s participation in the above-mentioned biblical encouragement ministry. It is further understood:
In consideration for receiving any form of counseling from the Bread of Life Counseling Center, the person receiving the counseling agrees to release and waive any and all claims of any kind against the ministry, the staff, the pastoral/lay encouragers or any participating church, which may arise from, result out of, or be related to conduct or advice given.
That all encouragement provided in this ministry is provided in accordance with the biblical principles adhered to by the Southern Baptist churches of the North Central Area Missions Program and is not necessarily provided in adherence with any local or national psychological or psychiatric association.
That the undersigned has read and understands the contents of the waiver, and consents to and requests said encouragement.
Signature
Parent or legal guardian signature (If counselee is a minor)
(Date)
{Clients who submit the intake form on line will be asked to sign this form upon first in-office visit.}
Personal Data Form – please fill out completely
Name:
Address:
City: State: Zip:
Yrs. At address: Email:
Phone: Home:
Phone: Work: Cell:
In case of cancellation or reschedule, at what number can you be contacted?:
Sex: Male Female Date of Birth: Age:
Occupation:
Employer:
Marital status: Single Engaged Married Divorced Widowed
Name of spouse: Age of spouse: Yrs. Married:
Spouse’s occupation: Employer:
This is your marriage. This is your spouse’s marriage.
Names and ages of children (indicate children from previous marriage with an “*”)
Who referred you to the Bread of Life ministry?:
Name: Relationship:
HEALTH/COUNSELING/LEGAL DATA
1. Are you presently under the care of any medical doctor/practitioner? Yes No
If yes, for what:
Dr.’s name: Phone:
2. Are you currently taking any prescription or non-prescription medications? Yes No
If yes, please indicate type and dosage:
Prescribed by whom
3. Are you aware of any physical problems that impair your functioning? Yes No
4. Are you currently receiving or have you in the last 3 years received counseling, individual or marital therapy, or been under the care of any mental health provider or addiction recovery provider?
Provider’s name: Phone:
Address:
For what issue?
May we contact this provider for additional information? Yes No
5. Have you ever been hospitalized or been in an outpatient program for emotional issues or substance abuse? Yes No
If yes, please list when, where, and for what issue:
6. Are you currently involved in, or anticipate being involved in any litigation or legal action?
Yes No
If yes, please explain:
CHURCH BACKGROUND
What church do you currently attend? Are you a member? Yes No
Do you know for certain that if you were to die tonight that you would go to heaven? Yes No
Would you like to discuss this with your counselor? Yes No
Has there been a time in your life where you have received forgiveness of sin and accepted Jesus Christ as
your Lord and Savior? Yes No Unsure
When did you do this? Have you been baptized? Yes No
Have there been any recent changes in your spiritual life? If so, what changes have occurred?
PRESENTING PROBLEM(S)
Please state, in your own words, the problem you are experiencing:
What is your goal in seeking help?
Are you open to Biblical and spiritual guidance for this issue? Yes No
Is the use/abuse of drugs and/or alcohol related to this problem in any way? Yes No
If yes, please explain:
Have you experienced any significant loss / crisis life change recently?
Please place a check mark beside any descriptions of what you are currently experiencing:
Anxiousness Depression Anger
Confusion Fear Loneliness
Despair Thoughts of suicide Hurt
Guilt/Shame Withdrawing from others Distance from God
Please answer the questions below honestly. It is our commitment to provide Biblical counseling to any person in need regardless of their ability to pay. However, in order to serve as many people as possible, we ask those that can pay for their counseling services to do so. Charges for counseling services will range from $0 to $85 per hour, depending on your ability to pay.
Note: if you are married, information on both yours and your spouse’s finances must be provided.
Name: Date:
Members of household and age of each: Relationship to you:
Your employer:
Your monthly salary: Yrs. with employer:
Your spouse’s employer:
Your spouse’s monthly salary: Yrs. with employer:
Do you receive any additional income (child support, alimony, other)? Please describe type and amount:
Monthly living expenses:
Rent or mortgage payment:
Utilities (all total): School / College tuition: Car payments (all total) :
Credit card payments (all total):
Childcare:
What amount, if any, do you believe you can contribute to your counseling sessions:
Unlike most professional counseling agencies which operate on a strict fee for services basis Bread of Life operates on a services for need basis. That is, if you are in need we want to help! You and your emotional and spiritual health constitute our highest priorities. We believe that God has called and equipped us to perform the important task of walking alongside hurting individuals and families so that they may know the joy of recovery and restoration.
Bread of Life Counseling Center is a ministry funded in part by a temporary agreement with the Georgia Baptist Health Care Foundation, the generosity of Foothills Community Church, the gifts of other local churches and the personal donations from counseling clients. It is our desire at Bread of Life Counseling Center to provide quality Christian, biblically-based help to those in need regardless of one’s financial situation or ability to pay counseling fees. With that in mind we wish to share with you how you can help make this ministry a continuing reality for those in need.
Upon your first visit to Bread of Life Counseling Center you will meet with our Director, Garry Barber. At this time you will be provided with an envelope addressed to Bread of Life Counseling Center 13724 Hwy 53 Marble Hill, GA 30148. We ask that once a payment amount is decided upon (based on our $0 to $85 per session scale) you use the addressed envelope to mail your fee payment to Bread of Life Counseling Center. If you prefer to deliver your payment in person you may do so by placing your fee payment in an envelope and delivering it to the counseling center Director in person.
Charitable contributions other than those made for the payment of counseling fees are welcomed, very much appreciated and tax deductible.
Checks are to be made payable to “Bread of Life Counseling Center”.
Thank you for your participation in this ministry!
