COUNSELING | Intake Form

Your name *

Email address *

Phone number *

Address *

Birthdate *

Marital status *

Which campus do you attend *

If not River Valley, which church *

Type NA if not applicable

HEALTH INFORMATION

Emergency Contact Name *

Emergency Contact Phone Number *

What groups are you active in *

Type NA if none

Rate your health *

What concern are you hoping to address *

What have you tried that isn't working *

What are you hoping we can do for you *

Are you receiving other counseling at this time and how is it working *

I feel depressed *

I feel anxious and fearful *

I worry *

I have low energy *

Anything else you would like us to know *

Release/Consent for Counseling *

I have read, understand and accept the information and guidelines that have been emailed to me. I do hereby give my consent for pastoral counseling. Type your name above to agree.

River Valley Church Pastoral Counseling Information and Agreement

By checking this box, I acknowledge that I have read the above information and understand the nature of the pastoral counseling services provided. *

To be fully informed about your pastoral counseling, please review the explanation and agreement statements below. These agreements must be submitted before your first appointment. (Note: Couples will need to submit individual forms.)

River Valley Church provides pastoral counseling services on a suggested-donation basis. Generally, individuals are referred to our designated staff pastoral counselors. However, in certain situations, a pastor may determine it is best to facilitate these counseling sessions personally.

I understand that this ministry offers biblical guidance and coaching to help me navigate life's challenges and deepen my walk with Christ. *

At its heart, pastoral counseling is a ministry of walking alongside one another. It offers one-on-one coaching, mentoring, and biblical guidance to help navigate life's challenges. Our goal is to help you find healing, restore your relationships, and deepen your understanding of who you are in Christ.

I understand the suggested donation is $25 to help invest in this ministry, but it is optional if I cannot afford it. I also acknowledge that insurance is not accepted. *

Cost & Investment To sustain this ministry, we suggest a minimum donation of $25 per session. This reduced rate is possible because River Valley Church subsidizes the cost of care. Please note that this is a suggested donation; we are committed to serving everyone regardless of their ability to pay at this time.

How to Give: Contributions can be made at the Receptionist’s desk or via our website under the “GIVE” tab.
Note: We do not accept insurance but can provide referrals to licensed professionals if needed.

I understand that while similar approaches may be used, this counseling is distinctly Christ-centered and Bible-based. *

How Is Pastoral Counseling Different from Regular Counseling? While pastoral counseling utilizes some of the same therapeutic approaches as secular counseling, it is distinct in its foundation. Every session is Christ-centered and Bible-based. This ministry uniquely blends established counseling principles with the Christian faith to address your spiritual and emotional well-being.

I understand sessions are typically 50 minutes and that counseling is short-term. I acknowledge that counselors may refer me elsewhere if my needs exceed their training. *

Sessions average 50 minutes long. Please note that pastoral counseling is generally short-term and is not intended to be a long-term solution. The length of care varies by individual, but we reserve the right to refer you to other professionals or terminate counseling if we feel we cannot adequately meet your needs based on our training or experience.

I understand that River Valley counselors are ministers, not state-licensed therapists, and do not provide medical advice. *

Our team consists of licensed pastors and ministers with experience in biblical counseling. Please be aware that they hold ministry credentials rather than state of Oregon professional counseling licenses. We focus on spiritual care and do not offer medical or legal advice.

I understand that while anyone is welcome, the counseling provided will be Christ-centered and Bible-based. *

Do I Have To Be A Christian? No, our counseling is available to everyone, regardless of background. However, please be aware that our approach is strictly Christ-centered and Bible-based, as we seek to help individuals grow spiritually throughout their healing process.

By typing your first and last name below, you confirm that you have read and agree to comply with all of the above statements.

Adult Participant's First and Last Name *

Date Signed *

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