1. Client Name
*
First Name
Last Name
2. Is the client a minor?
*
If yes, then input the adult contact's information below (NOT the minor client's email/phone).
3. Contact Name
First Name
Last Name
4. Client/Contact Email Address on File
*
5. Client/Contact Phone
*
Country
(###)
###
####
7. If you requested a joint/couples session in the question above, who would you like to attend sessions with? (Please provide their full name, phone number, and email.)
8. What are your goals for this next session? What outcome(s) are you hoping to experience?
*
9. Why do you want to switch to a new minister/service?
*
10. What are you looking for in a new minister?
*
11. Have you ever been given a mental health diagnosis? 1.) What was the diagnosis? 2.) When was it given? 3.) Are you currently taking any medication for it? (Type "N/A" or "No" if this question does not apply.)
*
12. Do you want a video or in-person session?
*
Video session
In-person session
Either video or in-person is fine
13. What's your top priority when we assign you to one of our team members?
*
Appointment location preference (in person vs virtual)
Seeing the minister I mentioned above (I'll adjust my schedule if needed)
My availability
Soonest available appointment (I'll adjust my schedule if needed)
Whichever minister you think is the best fit for me (I'll adjust my schedule if needed)
My requested service
14. What's your second priority when we assign you to one of our team members?
*
Appointment location preference (in person vs virtual)
Seeing the minister I mentioned above (I'll adjust my schedule if needed)
My availability
Soonest available appointment (I'll adjust my schedule if needed)
Whichever minister you think is the best fit for me (I'll adjust my schedule if needed)
My requested service
16. Current Availability (PST)
*
Please tell us the days and times you're available for a session. The wider your availability, the more options we have to match you with.
17. If you've met with someone recently, are you planning to meet with them again in the next 1-2 months?
*
1) No, I'm not planning to meet with them again soon.
2) I'm not planning to book with them soon but would be open to meeting with them in the future.
3) Yes, I plan to book with my most recent minister soon, in addition to my new minister.
18. Is your credit card on file up to date?
*
Yes, my credit card on file is still good/correct.
No, please email me with options/instructions to update my card on file.
I believe it's still good, but I'm not 100% sure. I'll log in to my Client Portal to confirm/update my account as needed. (Please contact the TC office if you need assistance.)
20. Is your contact information on file (home address, phone number, email address) correct?
*
Yes, what I submitted previously is correct.
No (or I'm not sure), so I'm listing my updated information below.
21. Updated Home Address (if applicable):
22. Updated Email Address (if applicable):
23. Updated Phone Number (if applicable):
Country
(###)
###
####
24. We periodically update our policies and want to make sure you have our latest information. How will you access and review our most updated policies?
*
I will review the extensive policies on tcbethel.com/disclosures
I'd like a copy of the summarized policies.
25. Would you like to fill out a new intake form so you can provide greater detail for your minister's reference?
*
Yes, please send me an intake form
No, I will share details here. Do not send me an intake form unless necessary.
