Main Telephone Number for Northeast and Southeast, Florida - 904-580-5755
Intake Tool Form 4 of 4
This entire packet must be completed by, or for, each individual participating in any service provided by BCHH.
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.
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.
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. https://www.hhs.gov/ocr/index.html
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: