LIFEBACK INTAKE FORM

Thank you for reaching out a taking the 1st step toward recovery, it is our greatest desire to see you whole and to be a part of your healing process. In order for us to counsel you to the best of our abiility and to schedule an appointment, it is necessary for us to collect the following information. Please take a moment to complete the entire form to begin the intake process. Once you submit the form your information will be forwarded to our Counceling Center and they will contact you to schedule your next step. Please be aware there is a $35.00 Administration fee for all appointments.

Sincerlely

GO Church

Lifeback Counseling

NOTICE

If this is an Emergency Situation concerning your Safety or Mental Health, or that of another, 

please STOP NOW and call 911

 

HOW ARE YOU FEELING RIGHT NOW ON A SCALE OF 1-5?

Physically

Socially

Emotionally

Spiritually

 

RELEASE OF LIABILITY AND STATEMENT OF UNDERSTANDING

 

Being legally competent and fully authorized and empowered to do so, you agree to hereby release, acquit and forever discharge Peter Chimento, LifeBack Counseling Center and Go Church, staff and those associated with them from any and all actions, course of action, claims, demands, damages, costs, loss of service, expenses and compensation, on account of any and all known and unknown personal injuries, mental anguish or agitation and damage claims to person or property resulting or arising out of or related to services provided by Peter Chimento and LifeBack Counseling Center and/or its agents, representatives and/or employees in any way affecting the undersigned parties. 

It is further understood and agreed that this waiver and release constitutes an admission and acknowledgement by this undersigned that they have received no warranty, guarantee or promise of any particular result either expressed or implied. The undersigned acknowledges that the very nature of the problem(s) is necessarily such that no specific result(s) can be promised or warranted.

I am also aware that Peter Chimento of LifeBack Counseling Center is mandated by law to intervene if he suspects that I am a danger to myself or others. 

No Court Testimony: The counseling we provide is faith-based and spiritual in nature. That prohibits compelled disclosure of counseling exchanges, notes or records in a court of law. Accordingly, LifeBack Counseling Center and its counselors will not provide court testimony or letter to the court and by signing below you are acknowledging this strict confidentiality and further agree that neither you nor your legal representative will attempt to subpoena your counselor.

I understand that I am free to leave my session at any time and that I am in session voluntarily. Also, if for any reason Peter Chimento feels it is necessary to terminate further counseling sessions it is understood he may do so.

I believe that Peter Chimento who is leading these counseling sessions to be an encourager in the Christian faith and one who is helping me assume my responsibilities for finding freedom in Jesus Christ.