Online Intake Form(Downloadable forms are below)

FAMILY BACKGROUND

Are your parents living?

Are they living together

Are Your Parents Divorced

Did any of your parents remarry

Was your relationship with your mother

Was your relationship with your father

How was your relationship with your siblings growing up?

Where there any instances of abuse in your family? (check applicable box)

MOOD INVENTORY

Do you have any of the following symptoms?Or diagnosed with any of the following? (Check the ones that apply to you)

Have you personally ever received psychiatric treatment?

Has any member of your family ever received psychiatric treatment?

Feel mentally confused?

Self medicate (through alcohol, sex, food, work, entertainment, etc.)?

Have short term memory loss?

Have panic attacks?

. Hear voices in your head?

Are you now undergoing psychiatric treatment?

Are you currently on medications?

ADDICTION RECOVERY

Have you ever felt you had/have a problem with any of the following:

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Downloads for Your First Visit

Starting your journey with FMB Christian Counseling is an important step, and we want to ensure the process is as smooth and transparent as possible. The documents available for download on this page are essential tools that allow us to understand your needs better and ensure the utmost care and guidance tailored just for you.
● The Benevolence Form is an essential tool in our commitment to making counseling accessible to all. While the standard fee per session is $75.00, we understand that financial circumstances vary. If you're seeking a reduced rate or financial assistance, it's necessary to fill out the Benevolence Fund application, which covers Reduced Rate and Sliding Scale options. Please note that the availability of sessions at reduced rates may be limited, so early application is encouraged to best accommodate your needs.● The Intake Form gives Fawn an overview of your history and present challenges, allowing her to understand what counseling approach will be most suitable to your needs.● The Statement of Understanding provides clarity about our therapeutic relationship and sets the foundation of trust between us. ● Lastly, the Credit Card Authorization Form ensures a seamless process for any potential transactions.
Please take a few moments to download, fill out, and bring these forms with you to your first session. This not only accelerates the initial processes but also allows more time to focus on what truly matters – your healing and journey ahead. Rest assured, all the information you provide is treated with the highest level of confidentiality and respect. We look forward to embarking on this transformative journey with you.

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Fees for counseling services are required at the time of the appointment. The standard fee is $75.00 per session. Additionally, a one time fee of $55.00 is required for your first session to complete the Arno Profile System (APS) test. If a reduced rate or financial assistance is being requested, a Reduced Rate, Sliding Scale and Benevolence Fund application is required. The number of sessions available for reduced rate clients may be limited.
There is a $3.75 per transaction fee for all credit card payments. Cancellations not made 24 hours in advance may result in a $55.00 cancellation fee.

CONTACT US TODAY

Having a Hard Time? Let's Talk!

Call me 512-438-9464 or write to MOC.LIAMG%40LLUBNWAFROLESNUOC