Thank you for allowing us to be a part of your treatment team.Please take a moment to complete the form below to help us better serve you. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referred by Emergency contact name * Emergency contact number * (###) ### #### Highest grade or college level completed Current employer Current position Previous employers and positions Have you ever served in the military? Yes No Preferred religion or denomination Do you attend church? Yes No If yes, name of church Name of Primary Care Physician PCP phone number (###) ### #### Approximate date of last medical exam How would you rate your current health? Excellent Good/Average Declining Very poor Would your PCP agree with your rating? Yes No Height Weight, if known Please list all significant treatment, hospitalizations, surgeries, illnesses, diagnoses, and/or disabilities with their approximate dates of occurrence. Please list all medications, dosages, and approximate start dates of prescriptions. Do you currently, or have you ever used drugs for anything other than medical purposes? Yes, I currently do. Yes, I have done so in the past but not currently. No, I have never done so. If you answered yes to the question above, please describe use. Alcoholic consumption Never Very rarely On occasion Weekly A few times a week Daily More than once per day Do you smoke or vape? Yes, I currently do. No, I never have. No, I don't now but have in the past. Are you currently and/or have you previously seen a coach, counselor, or other mental health clinician? Yes No If you answered yes to the above question, please provide dates of service, treatment/diagnoses, and outcomes. Have you experienced any major traumas? Yes No I'm not sure Are you willing to sign a release of information for us to communicate with other clinicians on your team, if deemed necessary? Yes No I'm not sure at this time. Marital status If married, please list spouse's name, date of birth, and cell phone number. Do you have children? Yes No If you do have children, please provide the following information for each child: first name, age, sex, any special circumstances (if applicable). Were you raised by anyone other than your biological parent(s)? Yes No It's more complicated than yes or no Please list your siblings and ages in birth order. Are you on good terms with your mother, father, brothers, and/or sisters? Have you ever been arrested and convicted or a crime? Yes No Are you involved, or do you anticipate being involved, in any legal actions? Yes No Maybe Describe your greatest struggles, as you understand them. How can we best help you? What are your expectations for BYB services? Is there anything else you would like us to know, prior to your first session? ACKNOWLEDGEMENTS Please type your initials into the box provided, acknowledging you understand and consent to the terms described. Foundation: Our services are based upon biblical priniciples. Most of our coaches are not mental health professionals. Our therapists are mental health clinicians, and client and therapist must both live in the state of existing licensure. Coaching services with licensed therapists are for coaching services only. They are not clinical, therapeutic sessions. * Confidentiality: Confidentiality is an important aspect of this process, and we will carefully guard the information you entrust to us. There are, however, situations in which our team members may deem it necessary, biblically and/or legally, to share specific information with others. This includes, but is not limited to, the following situations: when there is concern that someone may be harmed unless others intervene; when abuse or another crime may have occurred; when observations for interns are required (with client permission only). *Please be assured that our team members strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve an issue as privately as possible. We will uphold all mandatory reporting laws at all times. * Client fees: Please select the service you're requesting with Charis Eating Disorder Care. Cancellations should be made at a minimum of 24 hours in advance to avoid an additional no show fee of $50. * By selecting the service below, you acknowledge understanding of financial responsibilities, including no show fees. Coaching sessions (45-60 min. session): $75/session Coaching package (45-60 min. session w/support): $110/week LMH therapy sessions (45-60 min. sessions): $100/session Minors: When clients are under the age of 18, we require parents to be involved in the coaching process. This could include, but is not limited to, the following: coaching sessions, homework, and/or accountability for the minor. Conflict Resolution: On rare occasions, a conflict may arise between a Charis Eating Disorder Care team member and client. In order to ensure that any such conflicts will be remedied in an appropriate manner, we require all of our team members to agree that any dispute that arises with a coach, therapist, or within the ministry of Charis Eating Disorder Care, as a result of our services, be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure of the Institute for Christian Conciliation; judgement upon an arbitration award may be entered in any court having jurisdiction, it is expressly understood that by agreeing in advance to arbitrate that the cient is giving up his or her right to a trial in the civil courts. Charis Eating Disorder Care team members are contracted consultants and are not employees of Charis Eating Disorder Care. * Conclusion: Having clarified the principles and policies of our services, we welcome the opportunity to work with you and help equip you for living life in freedom. If you have any questions about these guidelines or conditions, please speak with our Executive Director. My initials below confirm that principles and policies have been clarified, and I do not have further questions at this time. Signature: Having read the foregoing information and conditions fully and completely, by signing/typing my name in the space below, I indicate that I understand all the material presented and fully agree to comply with the foregoing, and I consent to the disclosure of certain communications as provided above and waive any legal privileges that may apply. Date of signature MM DD YYYY Thank you!
