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Intake Tool
Form 4 of 4


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

  2. Each section of this form must be initialed, and the form signed by the client, or the client's guardian as identified in this packet.

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

General Counseling/Coaching Intake Packet


Informed Consent, Confidentiality Covenant, and Religious Disclosure

Section A

Counseling Philosophy

BCHH believes that since the One who created us divinely inspired all biblical scripture, the Bible is the absolute final authority on all things pertaining to humanity – including human behavior.

“Every scripture inspired of God is also profitable for teaching, for reproof, for correction, for instruction which is in righteousness” (2 Timothy 3:16, ESV).

As such, all teaching, counseling, coaching, and psychotherapy are biblically based and tested; all correction goals are biblically aligned; and outcomes are evaluated according to biblical standards. It is BCHH’s firm belief that an intention to emulate the Lord helps people of all ages adjust away from poor behaviors (behavioral Adjustment), and that developing a kingdom mindset will help establish strong reasoning skills (cognitive Adjustment). BCHH believes this kingdom perspective and an abiding faith in the authority of Jesus Christ allows Him to fully function in one’s life. Moreover, the LORD is fully and independently capable of providing deliverance from all things causing emotional anxiety and behavioral dysfunction, giving way to a secure, faithful, and hope-filled life of peace.

Section B

Counseling Methods (Psychology & Science)

For Christian therapists, psychology provides a set of tools that can be used in helping identify how one’s humanity affects a care seeker’s connection to the Lord, and how their interactions with the world, social environment, family structure, and past experiences affect their emotional, spiritual, relational, and personal development conditions. As such, it is BCHH’s intention to assist care seekers in briefly identifying their past story and defining a new story by eliminating negative behaviors and concepts from their lives, and establishing a better and healthier outlook on their future. To do this, the counselor and the counselee prayerfully invite the Holy Spirit to join together with them to build a new future. In some cases, the counselee is given homework that may include biblical or book reading. However, counseling sessions are driven or guided by the counselee to ensure the best possible outcome.

In most cases, standard individual and couples sessions will be conducted by Board Certified Christian Counselors, Board Certified Pastoral Counselors, Certified Christian Mental Health Coaches, or Christian Interns who will take notes and provide immediate or delayed feedback. Approximately 30 minutes into each session a 5 to 15-minute break may be taken to give all involved an opportunity to reflect on the session and prepare for the session’s conclusion. In some cases, the counselee will be given an assignment to complete during the break, which will be collaboratively utilized after the break.

You, the counselee, must understand that the counseling process is intended to help you reach for and achieve whatever you came to counseling to achieve. For the most part, the work that will be done will be done by you – we hope you will allow for a powerful influence from the Holy Spirit. It should not be your expectation that BCHH will “fix you”. Your participation and intentionality will drive your ability to imagine and reach your counseling goal.

Section C

Definition of Christian and Pastor Counseling


Although we do not have a problem with using state-licensed practitioners, our counselors are intentionally not state licensed. We believe licensed counselors are not as free to practice counseling using a biblical foundation as is necessary to bring about true freedom for our clients. Likewise, our counselors are not those who are known as Biblical Counselors. Although all of our staff rely on biblical standards to moderate our programs, Biblical Counseling rejects the validity of psychology. Our practitioners are fully engaged with God and the study of the mind that He created.

College and seminary-educated Christian and Pastoral counselors are fully trained in psychology and spiritual aspects of human behavior and social interaction. Our concept of psychology is that it is the study of the created mind, just as science is the study of all that is created. Because of this position on science and psychology, Christian counselors and Pastoral counselors attend to mental health like any other psychology practitioner, but also focus on spiritual health. Christian and Pastoral counselors are highly educated, as are those who serve in support roles, such as Mental Health Coaches (C-MHC) and interns.

A Board Certified Christian Counselor is required to have a minimum of 6 years of experience and possess a minimum of a master's degree in ministry-related counseling, which includes psychology or is backed up by a Bachelor of Science degree in Psychology (156 hours of education). Our Board Certified Christian Counselor also has a Doctorate Degree in Pastoral Counseling (D.Min) identifying him as a Christian Psychotherapist (222 hours of education). Board Certified Pastoral Counselors are required to have a minimum of a Bachelor's degree in Christian Counseling, which includes the study of psychology with a specialization in Christian Counseling, and must have a minimum of 6 years of pastoral experience (120 hours of education plus seminary hours). Certified Mental Health Coaches (C-MHC) have completed 40 hours of training in psychology and Christian Spiritual Counseling while Board Certified Mental Health Coaches (BC-MHC) have the same training but, like all of our Board Certified practitioners, must also participate in Continuing Education every year.

By initialing this section and signing this document you certify that you have been informed that your counselors who are affiliated with BCHH are not state-licensed practitioners and are certified by the International Board of Christan Care (IBCC) and either the International Board of Professional and Pastoral Counselors (BCPPC), the Board of Christian Mental Health Coaching (BCMHC), or are certified as Mental Health Coaches by the American Association of Christian Counselors (AACC).

Section D

Session Limits

BCHH limits its sessions to a maximum of one and one-half hours for single individual and couples sessions, and two hours for workshop and group sessions. The anticipated duration of pastoral/Christian counseling programs will be defined by the care-seeker and the counselor at the end of the first session. However, the maximum number of weekly sessions permitted for any particular program is ten (10), with the exception of programs designed specifically as long-term maintenance or care programs (LMCP).

Section E

Session Fee

BCHH is a non-profit ministry that charges based on an income-based sliding-scale. Your income will be evaluated to determine your per-session rate at the beginning of your introductory session. Session fees are collected at the beginning of each session.

The sliding-scale rate chart can be requested at  the BCHH office, via your counselor or coach, and online at

Section F

Referral Extension

If BCHH realizes care limitations and finds it necessary to refer a counselee to a different therapist who specializes in an area of care that is necessary for goal attainment, it may indeed refer the client to such a third-party practitioner. If referral to another professional counselor, therapist, or pastoral/Christian counselor is necessary, BCHH will remain connected to the counselee as necessary and desirable. Because we intend to remain involved in your overall care, we identify most referrals as referral-extensions, as opposed to terminating- referrals, which would indicate the termination of services upon initiating a referral. Insomuch that we may not be active in working collaboratively with your new practitioners to avoid interfering with their program, your progress, or your privacy, we will remain available to you for nonrelated needs. In the case you must be referred to one of our partner professionals or other practitioners, you will receive a written explanation of why it is necessary and what to expect initially and over the long-term from BCHH. Also, if it is necessary for goal attainment or if it is in the best interest of your overall mental and spiritual health, BCHH may desire to share all or part of your health records, or a summary of the same, with the practitioner to whom you are being referred. In such a case, your health information will not be shared with the third-party practitioner(s) without your expressed written permission.

Section G

Religious Foundation and Non-Discrimination

BCHH does not exclude non-Christians from receiving education-based counseling through this service. In fact, we encourage all people to study the material we provide and apply it in their lives. We believe that the morals, standards, and advice provided in the Holy Bible are intended for all mankind; even if the reader refuses to accept its origin. We believe that since all of our methods are biblically based, they are all valid and applicable to everyone’s lives. By signing this form you acknowledge that BCHH and its staff are free to express their Christian principles based on standards believed to be derived from the Holy Bible, which may not agree with your (the care-seeker) views. This is further made possible and even likely as this organization requires all counseling and administrative staff to be in agreement with our Core Beliefs, which are biblically based. Even though our staff is trained to be sensitive to other worldviews, our solutions are biblically derived, making separating from them difficult, if not impossible. However, our staff also agrees not to judge or discriminate against a counselee because of their beliefs.

Section H

Section I

Section J

Ethical Foundation

This service ascribes to ethical standards set forth by the American Association of Christian Counselors. We believe this peer association provides us the strongest level of social and biblical accountability, to provide you Pastoral/ Christian counseling coaching, and mentoring services in a fashion that exemplifies biblical moral responsibility.

Section K

Section L

Telehealth is live two-way audio and video electronic communications that allows therapists and clients to meet outside of a physical office setting. This increasingly popular meeting method may be necessary if the client or counselor is not able to meet in person, but meeting is necessary to keep up program momentum. Please consider the value of telehealth sessions and agree in advance if the following is acceptable to you.

Client Understanding

  1. I understand that telehealth services are completely voluntary and that I can withdraw this consent at any time.

  2. I understand that none of the telehealth sessions will be recorded or photographed.

  3. I agree not to make or allow audio or video recordings of any portion of the sessions.

  4. I understand that the laws that protect privacy and the confidentiality of client information also apply to telehealth, and that no information obtained in the use of telehealth that identifies me will be disclosed to other entities without my consent.

  5. I understand that telehealth is performed over a secure communication system that is intended to be secure and private, and that BCHH will do its very best to be sure my video sessions are accessable only to me, my counselor(s), and their supervisors. Nonetheless, I understand that any internet-based communication is not 100% guaranteed to be secure. I agree that the therapist and BCHH will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.

  6. I understand there are potential risks to communication technology, including interruptions, unauthorized access, and technical difficulties. I understand that I or my therapist may discontinue the telehealth sessions at any time if it is felt that the video technology is not adequate for the situation.

  7. I understand that if there is an emergency during a telehealth session, then my therapist may call emergency services and/ or my emergency contact.

  8. I understand that this Informed Consent for Telehealth agreement exists in addition to other official notices and consent agreements between me and BCHH and that all office policies and procedures also apply to telehealth services.

  9. I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re-contact.

  10. I understand a “no show” or late fee will be charged if I miss an appointment or do not cancel within 24 hours of a scheduled appointment.

  11. I understand credit card or other forms of payment will be established before the first session.

  12. I understand that the check-in process of each session will be a part of the total time allocated for my sessions, and I understand that it is recommended that I check in just prior to my appointment by visiting and clicking on the appropriate check-in button.

  13. I understand my therapist will advise me about what telehealth platform to use and that they will establish the video conference session that I will need to join.

By my signature below, I, the person identified herein,  acknowledge having read and understood all of the contents of the Informed Consent, Confidentiality Covenant, and Religious Disclosure form, including the HIPAA Disclosure section, and agree to its terms. Additionally, I agree to harmlessness Baymeadows Center for Hope & Healing, Inc., its staff, affiliates, and associates, from any claims of discrimination as explained and identified herein.

After you click Submit, you will be taken to the ClientCenter page.

Alternate Lifestyles

BCHH defines alternative lifestyles as any personal or relational behavior that is contrary to those presented in the Holy Bible as acceptable to the Lord. We are a full gospel ministry, which believes that every word of the Holy Bible is true and therefore understands that certain behaviors are unacceptable to the Lord and are considered sin and/or abominations. As such, we will educate persons having such desires or propensities to abstain from them. We do not exclude persons of alternate lifestyles from receiving education-based counseling through this service. In fact, we encourage all people to study the material we provide and apply it in their lives. By signing this form, you acknowledge that this organization, its staff, and its partners are free to express, through their counseling, advice, and comments, Christian principles based on standards believed to be derived from the Holy Bible, which may not agree with your (the care-seeker) views. This is further made possible and even likely as this organization requires all counseling and administrative staff to be in agreement with our Core Beliefs, which are biblically based. Even though our staff is trained to be sensitive to other worldviews, our solutions are biblically derived, making separating from them difficult, if not impossible.

Restrictions and Exceptions of Private Client Information Sharing

BCHH believes that persons using our Pastoral/Christian counseling and mentoring service have a right to privacy. As such, we will not knowingly allow any information provided through our association to fall into the hands of any party not authorized by you. We do not provide free of charge or sell any client information to any other services or parties, public or private, for any reason.* BCHH employs paid and volunteer confidential secretaries, assistants, and interns who are bound to the same ethical standards as the counselors to whom they are assigned.

  • Law Enforcement Exception. In the case a counselee indicates an intention to do harm to himself/herself, any other party, including family members, other clients of this organization, its staff, or other parties not directly involved with our service; this organization will contact the proper authorities with as much information as is necessary to thwart the indicated dangerous outcome as required by Florida Statutes Sections 741.28, 741.31 and 784.046 and other applicable state and federal laws.

  • Court/Legal Proceeding: If a client is involved in a court proceeding and a court order is issued for information about the client's counseling services from Family Health 360/BCHH and/or requests records, we are required to provide the requested information to the court.

HIPAA Disclosure

Baymeadows Center for Hope & Healing, Inc. is required to make you aware of our privacy practices according to the guidelines setforth by the  in the HIPAA Privacy Rule of the Office for Civil Rights of the U.S. Department of Health & Human Services.


This section is included in your intake packet as it contains information on how to obtain a copy of the HIPAA rules and provides a place for you to verify that BCHH has provided you access to the rules, and that you understand them.

You can access a copy of the HIPAA notice by visiting our website at:

You can also discover more information about HIPAA at the U.S. Department of Health & Human Services website at:

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