Youth Intake Form - Functional Christianity

Welcome to Functional Christianity. Thank you for considering discipleship counseling / mentoring for your child. It is our desire to see healthy children grow Spritually, Emotionally, and Physically. We desire they experience freedom to be children. We aim to provide a safe and positive environment for every child to deal honestly with their issues, to learn and grow, and to work through any struggles or questions they might have. Functional Christianity is committed to providing a safe place where believers can find hope, encounter Christ as Life, and discover their true identity in Him. It is when we come to the end of ourselves that God can and will be able to do His deepest work We look forward to walking along side you, Gary Layne Founder

CHILD'S INFORMATION

Parental/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

ADDITIONAL INFORMATION

MEDICAL INFORMATION

APPOINTMENT TIMES

Functional Christianity is not equipped for emergency crisis care. Our counseling model is a discipleship process which benefits counselees over time. In situations involving suicidal counselees, where time is of the essence, we refer out for psychiatric and/or psychological care which may include inpatient treatment. Once stabilized, our desire it to assist hurting people on their journey to spiritual, mental, and emotional healing.

Financial Policy

Functional Christianity is a ministry and is not underwritten by any church, denomination or organization. We have been providing counseling services to the greater Atlanta area for over 8 years and we have touched the lives of hundreds of individuals through individual and couples counseling. The journey to spiritual, emotional, mental and relational health is the best gift you can give yourself! An investment of your time and finances will reap an abundant return. Intensive sessions are 2.5 - 3 days and are fee based. In the event of financial difficulty, we may be able to adjust then fee slightly to accommodate your unique financial situation. If this applies to you, please do not hesitate to contact us directly. Please note: Because we are a ministry and do not provide psychotherapy, we do not satisfy Medicaid requirements and we cannot bill insurance companies.

First you will talk to a counselor about the issue(s) for which you are seeking counsel, and discuss potential next steps. At this time, we will also determine whether you would be best served by seeing a medical or psychological professional. Prior to visiting our home, you will fill out some online forms, which take some time to complete your assessment profile. After you complete the online assessment we can talk about scheduling your desired time frame. We reserve the right to refer a client out or discontinue discipleship counseling at any time. There is a 25% deposit required to start the process.

Intensive discipleship counseling sessions may be overwhelming as they deal with so many unaddressed pain issues. You may stop anywhere in the 3 day process if it becomes too much. Continued session may be required for complete healing to occur.

Confidentiality Policy

All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that I take during your sessions. I will not even verify that you are a client. You may choose to give me permission in writing to release any or specific information about you to any person or agency that you designate.
Limits to this agreement:

• In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court.

• If I learn of or believe that there is physical or sexual abuse or neglect of any person under 18 years of age, I must report this information to county child protection services.

• If I learn of or believe that an elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency that handles elder abuse.

• If I learn of or believe that you are threatening serious harm to another person, I am obligated to report this. This can be in the form of telling the person who you have threatened, contacting the police or placing you into hospitalization.

• If there is evidence that you are a danger to yourself and I believe that you are likely to kill yourself unless protective measure are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection

• There may be times when I consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used in order to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.