Intake | Restoration Counseling Center

Thank you for contacting Restoration Counseling Center in regards to how we might be able to walk alongside you to Restore Hope to Life.

Please read through the following agreement and initial, sign, and date the form prior to your first appointment.

I. Description of Counseling Your counseling will be based on Christian faith. Our aim is to come alongside you and provide wise and loving help by exploring what really matters. Your circumstances matter, so we will seek to understand what you are facing. Your experiences matter, so we will seek to understand how you are living in response to what you are facing. Who God is, what God says, and what God does matter, so we will seek to understand the Hope that he is for us in and through Christ, as revealed in the Bible. We believe deep and lasting change is brought about by God, himself, at the intersection of these things that matter. Our counseling will seek to help you connect the riches of this Hope to the realities of your life. Your counselor has theological and pastoral training and receives regular consultation and continuing education. Our goal is for biblical wisdom to guide the counseling process and content.
Initial here if you understand and agree with this Description of Counseling*

II. Counseling Goals We see the counseling process as having mutual responsibility. As an equal participant and counselee in the process you have the right to raise questions. Feel free at any time to request an estimate of the predicted length, goals, and desired outcome of the counseling. If you have concerns about the care and counseling you are receiving, you are encouraged to ask your counselor about alternative options. If you have legal, financial, medical or other technical questions, you should seek advice from a professional with expertise in those fields.
Initial here if you understand and agree with these counseling goals*

III. Fees
Restoration Counseling Center is able to operate because of your financial donations. The expenses of Restoration Counseling Center are not underwritten by an individual, church, or corporation. Therefore, it is through the donations of our counselees that the operating expenses of Restoration Counseling Center are met. The comparable-market-value for counseling in the Asheville area ranges from $75.00 to $125.00 per 50-minute session. Your responsibility is to pray about the amount God would have you donate for the counseling you receive and be faithful to God in your giving. Donations should be in accord with what a man or woman has, not according to what he or she does not have. Therefore, no one will be refused counseling because of the amount of his or her donation. We have made intentional efforts to keep our operating expenses extremely low. However, there are some expenses that are unavoidable. We receive checks, made payable to Restoration Counseling Center, or cash. You can also pay with credit card through our online donation page.
Initial here is you understand and agree with this Financial Policy*

IV. Appointment Cancellation Policy
As a non-profit ministry, Restoration Counseling Center must be a careful steward of our resources, including time. Therefore, we ask that you give at least a 24-hour notice for cancellations. If you fail to give us a 24-hour notice we would ask you to provide a $25 donation for your missed appointment.
Initial here if you understand and agree with this Cancellation Policy*

V. Confidentiality

Restoration Counseling Center is very sensitive to the issue of confidentiality. We will carefully guard the information you entrust to us. To release counseling information without your consent would violate both biblical standards and commonly accepted codes of counseling ethics. There are situations, however, where it may be required for us to share certain information with others.
- Abuse or Neglect: We are committed to protect the vulnerable therefore we will report to appropriate authorities if we believe a minor, elder or person with disabilities to be at risk or that abuse or neglect has taken place.
- Harm to self or others: We are called to protect life, therefore we will report to appropriate authorities if we believe a person to be at risk of life-threatening harm to self or others.
- Public Health: We live in community and are called to responsible relationship with others, therefore we will participate in the reporting of relevant information to a public health authority when mandated by law and for general health oversight.
- Legal Requirement: God has instituted authority for the establishment of justice and order, therefore we submit to legitimate requests for information needed for law enforcement purposes and also for the process of legal proceedings.
All of our counselors reserve the right to receive consultation with other biblical counselors for the purpose of providing the highest level of care. In these contexts anonymous questions are asked and every effort is made to safeguard the identity of each counselee. Confidentiality is applied by the consultation group as a whole.
Initial here if you understand and agree with this Confidentiality Policy*

VI. Coordinating Care

As biblical counselors we believe that others in the local church body can be helpful in most cases. We encourage you to give permission for your counselor to contact your pastor, elder, deacon, small group leader, or another friend so they can come alongside you in care and encouragement.
Initial here if you understand and agree with this Coordinating Care Policy*

VII. Help Between Sessions
In intensive crises we cannot guarantee that you will quickly reach your counselor. If you face any emergency, please dial 911. If you have an urgent message, call our main number (828-552-4889) between 9 AM and 5 PM, Monday–Friday (EST) to speak to someone. We will contact your counselor as soon as possible. You may also email the Executive Director of Restoration Counseling Center at jvallejos@rccavl.com.
Initial here if you understand and agree with this Help Between Sessions Policy*

VIII. Waiver of Liability

In seeking counseling from Restoration Counseling Center, you must acknowledge your understanding of the following conditions and further release Restoration Counseling Center, its staff, counselors, employees, Board of Directors, and all organizational leadership, from any legal liability, claim, or litigation arising from your participation in this voluntary program:

1. Counseling will be provided by ordained ministers or biblical counselors who are recognized as having exceptional character and leadership qualities by their church with at least a Master’s degree in counseling. The counseling staff is not a licensed counselor as an LPC (Licensed Professional Counselor), LMFT (Licensed Marriage and Family Therapist), LCSW (Licensed Clinical Social Worker), or LFBPPC (Licensed Fee-Based Practicing Pastoral Counselor) through the state of North Carolina;  

2. All counseling is provided in accordance with the biblical principles adhered to by Restoration Counseling Center and are not necessarily provided in adherence to any local or national psychological or psychiatric association for the evaluation and treatment of mental disorders and other conditions through the use of a combination of clinical mental health and human development principles, methods, diagnostic procedures, treatment plans, and other psychotherapeutic techniques;

3. No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the above-mentioned counselors, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions;  
Initial here if you understand and agree with this Waiver of Liability*

IX. Resolving Disputes
In the case of unresolved differences, you agree to participate in a process of conciliation. This involves: (1) meeting with the Executive Director of Restoration Counseling Center; (2) seeking to settle the dispute by mediation; and, if necessary, (3) settle it by legally binding arbitration. Each of these steps shall be carried out in accordance with the rules and guidelines of the Institute for Christian Conciliation, a division of Peacemaker Ministries.
Initial here if you understand and agree with this Resolving Disputes Policy*

Emergency Contact
Name*
First Name Last Name
Telephone*
Relationship to You*
Address*
City State
Do we have your permission to contact this person in case of an emergency?*
- No
- Yes

Marriage & Family Relationships
Marital Status*
- Single
- Steady Dating
- Engaged
- Married
- Separated
- Divorced
- Widowed
Spouse's Name
First Name Last Name
Spouse's Date of Birth
Date Format: MM slash DD slash YYYY
Spouse's Age
Spouse's Employer
Position
Years Employed
Cellular Phone
Business Phone
Date of Marriage
Date Format: MM slash DD slash YYYY
Length of Time Dating
Give a brief statement of circumstances of meeting and dating
Is your spouse willing to come to counseling?
- No
- Yes
- Unsure
Have either of you been married previously?
- No
- Yes
- Unsure
Who was married previously?
- Me
- My Spouse
Date Married
Date Format: MM slash DD slash YYYY
Date Marriage Ended
Date Format: MM slash DD slash YYYY
Children
If you have children, please complete the table below:
Name Age Gender (M/F) Living (Y/N) Year in School Lives at Home (Y/N) Step Child (Y/N) Married (Y/N)
Parents
Is your father living?
- No
- Yes
- Unsure
If yes, does your father live locally?
- No
- Yes
- Unsure
Describe relationship to your father:
Is your mother living?
- No
- Yes
- Unsure
If yes, does your mother live locally?
- No
- Yes
- Unsure
Describe relationship to your mother:
Number of Siblings
Did you live with anyone other than parents?
- No
- Yes
If yes, who did you live with?

Health Information
Describe your current health:*
- Very Good
- Good
- Average
- Poor
Do you have any chronic conditions (if so, what?):
List important illnesses and injuries or disabilities:
Date of Last Medical Exam
Date Format: MM slash DD slash YYYY
Results of Last Medical Exam:
Physician’s name & address:
How many hours of sleep do you average per night?*
Is this sleep restful?*
- No
- Yes
Have you ever used drugs for other than medical purposes?*
- No
- Yes
If yes, please explain (specific drug(s), amount, frequency, when you stopped, etc.)
Do you drink alcoholic beverages?*
- No
- Yes
How often?
How much?
Do you smoke?*
- No
- Yes
How often?
Have you tried to stop?
- No
- Yes
Are you experiencing changes any change or extremes in your emotions or mood?*
- No
- Yes
If you answered yes, please explain:
Have you ever seen a psychiatrist or counselor?*
- No
- Yes
If yes, please complete the table below:
Age Duration Counselor/Practice Issues/Topics Helpful? (Y/N)
Are you currently taking medication?*
- No
- Yes
If yes, please complete the table below:
Medication Dosage Frequency Reason Prescribed Date Began Taking
Are you willing to sign a release of information form so that your counselor may gather further information or collaborate care with others if it is in your best interest?*
- No
- Yes

By signing below, you agree to the following:
- I have read, understood and agree with the policies contained in this document,
- I grant permission for Restoration Counseling Center to render counseling services to me, and
- I also understand that Restoration Counseling Center may terminate services for noncompliance with the plan of care and/or agreed upon administrative issues, failure to keep or cancel appointments, violent behavior, threats of violence, involvement in criminal behavior, or for other similar issues.
Enter Your Full Name*
By entering your fullname this will signify your signature.
Signature
Signature of a parent or guardian is needed if the counselee is a minor or unable to sign for his/her self.
Date Signed*
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Personal Information

Emergency Contact

Marriage & Family Relationships

Children

Parents

Spiritual/Religious Information

Health Information

Previous & Current Struggles

Name	Age	Gender (M/F)	Living (Y/N)	Year in School	Lives at Home (Y/N)	Step Child (Y/N)	Married (Y/N)

Age	Duration	Counselor/Practice	Issues/Topics	Helpful? (Y/N)

Medication	Dosage	Frequency	Reason Prescribed	Date Began Taking