Counseling Intake Form

Thank you for your interest in pursuing counseling at Jacob's Well Church. Please take a moment to fill out the following form so that we can understand how we might be able to best serve you.

Someone will be in contact with you within the next 48 hours to follow up and discuss possible next steps toward meeting with someone.

Please be assured that the information you provide for us will remain strictly confidential. If you have any questions about the confidentiality statement on this form, please contact Pastor Dan Jackson at danjackson@jacobswellgb.org.
 
 
 
 
 
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CONFIDENTIALITY

We are committed to maintaining any information our registrants entrust to us in a confidential manner. Your intake form will be carefully reviewed by the the Jacob's Well Church staff and then referred to one of our counseling staff for follow-up. Our referrals are based on the particulars of your registration and the areas of expertise and availability of our counselors. However, there are times when we are legally required and/or biblically obligated to share information with others. Therefore, we reserve the right to disclose limited information provided to us based our judgment and/or on the following exceptions (which is NOT an exhaustive or comprehensive list):

1. We are informed of alleged or suspected child/elder abuse or neglect committed by or experienced by the registrant or by a specifically identified individual,
2. The registrant is a perceived threat to themselves or others,
3. The staff is subpoenaed and ordered by a legal authority to testify or release registrant information,
4. The client or parent/legal guardian of the registrant provides a valid, written consent to release information to a third party,
5. The parent/legal guardian of an individual under the age of 18 requests information about the child, or
6. If the registrant is a member or regular attender at Jacob's Well Church and if we discern the need to discuss a client’s situation with his/her pastor, elder, and/or deacon for the purposes of providing pastoral assistance.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential exceptions to our standard commitment of maintaining all information provided to us by a client or potential client in a confidential manner, it is important that we discuss any questions or concerns that you may have prior to you providing any such information to us. When in our sole discretion we deem it possible and advisable, we will attempt to discuss the need to disclose any such information with the registrant/client prior to the our disclosure of such information. In addition, we reserve the right to conduct consultations with appropriate professional colleagues in a confidential manner to seek greater wisdom and insight in order to provide our registrants/clients with the best possible counsel.

This form will be seen by the counseling staff and a member of the Pastoral staff at Jacob's Well Church.
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Description

Thank you for your interest in pursuing counseling at Jacob's Well Church. Please take a moment to fill out the following form so that we can understand how we might be able to best serve you.

Someone will be in contact with you within the next 48 hours to follow up and discuss possible next steps toward meeting with someone.

Please be assured that the information you provide for us will remain strictly confidential. If you have any questions about the confidentiality statement on this form, please contact Pastor Dan Jackson at danjackson@jacobswellgb.org.