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Intake Tool
Form 3 of 4

Instructions

  1. This entire packet must be completed by, or for, each individule participating in any service provided by BCHH.

  2. If this form is being filled out by an adult for a minor child or a dependent adult under the guardianship of the one filling out the form, the child or dependent's information must be provided in all sections.

Baymeadows Center for Hope & Healing, Inc. (BCHH)

General Counseling/Coaching Intake Packet

FORM 3

Condition/Goals

Section A

If you are feeling unsafe or are experiencing thoughts of hurting yourself or others, call 911 or go to the nearest hospital emergency room.

Safety
Do you feel safe at home?
Are you experiencing thoughts of hurting others?
Are you experiencing thoughts of hurting yourself

Section B

Current Needs
Have you been treated for this condition in the last 5 years?

Section C

Current Condition

SELECT ALL THAT APPLY

I have recently experienced feelings of . . .

Section D

Spiritual History

By signing this document below, I am affirming to Baymeadows Center for Hope & Healing, Inc. (BCHH) that I have chosen to explore the possibility of receiving counseling/coaching services in the form of evaluation and psychotherapy from BCHH, or have chosen to receive counseling/coaching services in the form of evaluation and psychotherapy from BCHH. My decision is voluntary, and I understand that I may terminate these services at any time. I also understand that during the course of treatment, I may need to discuss personal and upsetting subjects to resolve my problems. Furthermore, I understand and accept that BCHH cannot guarantee that I will feel better after the completion of treatment.

After you click Submit, you will be taken to the next required intake form.

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