General Client Information and Informed Consent

Welcome to My Life Counsel

We're here to support you with our balanced approach that combines professional expertise, evidence-based research, and the guiding principles of biblical wisdom, all while emphasizing compassionate pastoral care.

Contact Information

For Person Responsible for Seeking Services

First and Last Name

Phone

Address

Client(s) Seeking Service

Please list the first and last names of the person(s) seeking services. If under the age of 18, then please list their age.

Birthday

Month

Day

Year

Types of Service

Please briefly describe the main reason(s) you are seeking counseling at this time:

Appointment Availability

Therapist availabilities range from Monday - Friday from 8am until 8pm.

Please list all the times that you are available for your therapy session. Note: Evenings are popular and could take longer for scheduling purposes.

Please request your most convenient times first and include a few secondary options.

*To ensure the quickest scheduling, please include all of your weekday availability.

Do you have any special needs, requests, or concerns about your assigned therapist?

Tell Us About Your Houshold

Relationship Status

First and Last Name of Significant Other's

Significant Other's Date of Birth

Please tell us about the people who live with you: 1. The number of people in your house, 2. their name, 3. age, and 4. relationship.

Household Annual Income

What is your place of Employment or source of income?

What is your partner's place of employment or source of income?

HIPAA (Health Insurance Portability and Accountability Act)

EMERGENCY CONTACT

You must fill out the emergency contact information in order to be HIPAA compliant. HIPAA (Health Insurance Portability and Accountability Act) requires certain information to be included in an emergency contact form to ensure compliance with privacy and security regulations.

Please include your emergency contact information.

First and Last Name of Emergency Contact

Relationship to Emergency Contact

Phone Number of Emergency Contact

Referrals

Please list how you found My Life Counsel.

Credit Card Information and Authorization Form

please fill out the details for your credit or debit card. HSAs are accepted.

Name of Person on the Card

Card Number

Card Expiration Date

CVC Code - typically a three or four digit code:

Zip Code

Credit Card Notice: To ensure the smooth handling of financial matters, a valid credit or debit card is required to secure your account in the event of no-shows, late cancellations, or NSF fees. Please note that the Accounting Department will not charge your card without your prior permission unless there is a violation of the agreement, such as the aforementioned infractions. You are welcome to use alternative payment methods, including cash or checks, for your sessions. Rest assured, credit or debit cards will only be used with your explicit authorization, except in cases where agreement terms have been breached.

Standard Intake Questionnaire

Counseling Goals

List 1 - 4 things that you would like to achieve from this counseling process.:

Complaint

What is your major complaint?:

Have you previously suffered from this complaint? If Yes, enter previous therapist(s) seen for complaint, describe treatment:

Aggravating Factors:

Relieving Factors:

Please tell your therapist about yourself.

We understand this can be a challenging exercise, so take your time and share as much as you feel comfortable. These fields are optional, but your effort to complete them will help your therapist gain a better understanding of who you are and how to support you on your journey.

Personal Narrative

Personal Narrative Tell your therapist about your personal narrative. This is the story you tell about yourself, shaped by experiences, beliefs, and interpretation of life events:

What is your self-perspective?

This is the way you view, understand, and interpret yourself, including your identity, abilities, values, emotions, and overall sense of self. It is essentially the lens through which you perceive and evaluate who you are in relation to their internal w

Express how you perceive your self-worth.

Self-worth refers to the value and significance you believe you have. For example, someone with positive self-worth recognizes that they are worthy of love, deserve to be understood and respected, and that their f

Add your text

Express how you perceive your self-esteem.

Self-esteem refers to your overall sense of confidence and self-respect, reflecting how you value yourself and your abilities. For example, someone with healthy self-esteem may feel capable, secure in their decisions, and resilient in the face of chall

Express how you perceive your interpersonal relationships.

How do you see yourself in relationships, including their role, worth, and impact on others:

Interests and Hobbies

What do you do for fun? List hobbies, sports, leisure activities and anything else that you enjoy doing:

Current Symptoms

Please check all that apply.

Anxiety

Panic Attacks

Irritabililty

Excessive Energy

Depression

Fatigue

Avoidance

Guilt and/or Shame

Libido Changes

Racing Thoughts

Panic Attacks

Sleep Changes

Risky Activity

Medical History

Do you exercise? What type of exercise? How frequent do you exercise?

Please list current and past mental health medications and a brief explanation of the purpose for prescription:

Do you have a previous diagnosis of mental health? If so, please share approximate dates and who you were treated by:

Please share any details about your family history that feel relevant to your story, including your parents’ relationship, your connection with them, and whether there’s any family history of mental health or relational patterns.

Present Situation

Please tell us about the status of your current relationship (dating, married, divorced, widowed) and how satisfied you are in the relationship.

Please include relevant information concerning past partners/relationships (partners, prior marriages, long-term relationships). Anything pertinent to your current mental health and well-being.

Please tell us if you have children. If yes, please share their names and ages. Tell us about your relationship with them. Please share your perspective on your partner's relationship with them.

Religion: 1. Please share your religious preference. 2. If you are a person of faith, tell us about how you live this out in your daily life. 3. Share which religious establishment you attend and your level of involvement. 4. Please share any other info:

Please tell us about your social support. List all the people you can count on. List all the social groups you attend on a regular basis. Share your level of desire to be social and if you are currently satisfied with your social life:

Have you ever tried the following?

Alcohol
Tobacco
Marijuanna
Hallucinogens (LSD)
Heroin
Methamphetamines
Cocaine
Stimulants (Pills)
Ecstasy
Methadone
Tranquilizers
Pain Killers

:Do you drink caffeinated beverages? If yes, how many per day?:

Have you ever abused prescription drugs? If yes, which ones?:

If yes to any, list frequency/dates of use:

Do you or your partner currently drink alcohol, smoke, or use other substance? If yes, what is the frequency? Example: Yes, my partner has two beers and I have a glass of wine every other day. Once a month we will have an occasional smoke (marijuanna).

Additional Information

Please share anything else you would like your therapist to know that will allow them to understand you, what your needs are, and what contributions your past and current situations have made to your overall mental and physical health and well-being.

Informed Consent for Counseling

I/we, the client(s), referred to as “I” or “the client,” have been informed by My Life Counsel, Inc. (referred to as “My Life Counsel”) that biblical counseling and spiritual faith-based guidance are being provided. This agreement shall govern the professional relationship between the parties. Any disputes or modifications of the agreement shall be negotiated directly between the parties.

If negotiations are not satisfactory, the parties agree to mediate any difference with a mutually acceptable third-party mediator, considering first either the Executive Director or a board member of My Life Counsel, Inc. In the event of a lawsuit, the client may assume all the costs of litigation, including adjunct costs, fees, and all attorney fees.

Credentials

My Life Counsel’s Executive Director, Dr. Scott Inman, Ph.D., is a commissioned minister of pastoral counseling, licensed by the National Conservative Christian Church for clergy ordination, and a certified temperament therapist with the National Christian Counselors Association. Dr. Inman holds a Ph.D. in General Psychology, an M.A. in Marriage and Family Therapy, and a B.A. in Psychology.

The Board of Directors and the Executive Director advise and supervise all staff, employees, and volunteers. My Life Counsel’s therapists and counselors are not secular psychologists or psychiatrists and are not state-licensed. Due to the pastoral nature of these services, My Life Counsel’s therapists, counselors, and interns will not testify in court or act as professional witnesses.

Consent for Counseling Services to a Minor

In order for minors, including youth and children, to receive counseling services, it is necessary for the parent or legal guardian to grant permission for such services to occur.

Only a legal parent or custodian of the minor child(ren) may consent. By digitally signing this document, you hereby affirm that you have the legal right to obtain treatment for the minor(s).

In instances of divorce, it is essential that the legal custodian of the youth/child(ren) grant permission for the services. If you are a divorced parent, stepparent, grandparent, guardian, or other custodian, you may be asked to provide a copy of the court order naming you as the legal custodian.

If you disagree with or refuse this statement, counseling services cannot be provided until a copy of the court order naming you as the legal custodian is provided. Both biological parents, even if divorced, may have the right to obtain information from the provider regarding the nature and course of treatment.

I, (named responsible party), consent to My Life Counsel, Inc. providing pastoral counseling services to the youth/child(ren). Furthermore, I understand that the policies contained in this Informed Consent apply to my child.

Confidentiality and Location

My Life Counsel goes to great lengths to protect your identity, personal information, and case notes.

My Life Counsel is located at 2300 SE 17th St, Ocala, Florida, in a professional plaza. Therefore, your identity cannot be guaranteed confidentiality in all cases. Others may see you waiting, entering, or exiting the building. My Life Counsel and your counselor cannot be held responsible if people see you interacting with us.

Web-Based, Online, Email, Text, or Phone Communication

My Life Counsel holds your privacy and confidentiality in the highest regard. However, security cannot be guaranteed for virtual, web-based, online, email, text, or phone communication. By choosing to communicate through these methods, you assume full responsibility for the security of such communication.

Faith-Based Biblical and Professional Counseling

My Life Counsel is a faith-based ministry dedicated to providing counseling services rooted in a biblical worldview. Our approach integrates spiritual guidance and professional expertise. Counselors may pray with and for clients, use Scripture as the foundation of counseling, and encourage personal devotions to support growth and healing.

This is Biblical Christian Counseling, distinct from secular counseling services. Some of our counselors are also state-licensed professionals who adhere to a Christ-centered approach.

While no guarantees can be made regarding counseling outcomes, success relies on honest participation, completion of homework, and a sincere faith effort. Together, we work toward healing and transformation grounded in faith and the love of Christ.

Confidentiality & Mandated Reporting

This ministry operates under the clergy/client confidentiality privilege, meaning communication between the client and the ordained minister of counsel is confidential.

However, as a mandated reporter, a counselor may break confidentiality without consent in the following cases:

Threat of serious harm to self or others
Child abuse or neglect
Abuse of the elderly or disabled
When otherwise required by law

“Reasonable suspicion” means credible evidence or circumstances that warrant further investigation by appropriate authorities.

Court Orders, Appearances, and Testimonies

Ordained clergy do not testify in court.

My Life Counsel operates under clergy/client confidentiality privilege. Counselors cannot write statements, testify, or appear in any court proceedings or hearings. Clergy cannot legally be subpoenaed by a judge or court officials. By signing this document, you acknowledge that there

will be no therapist/court interaction.

Insurance, Confidentiality Exceptions, and

Documentation

My Life Counsel offers superbills for reimbursement through certain insurance providers but cannot guarantee payment. HMOs, Medicare, and Medicaid do not accept superbills. Two Licensed Mental Health Counselors (LMHCs) at My Life Counsel are certified to accept Medicare.

When using insurance:

Clergy confidentiality privileges are limited.
An LMHC (e.g., Stephanie Smith or Vonitra Taylor) must conduct your intake and supervise your case.
A diagnosis and treatment plan will be created for insurance purposes.
Insurance companies may request access to progress notes and assessments.

If you prefer full clergy confidentiality, you may choose private pay and not use insurance reimbursement.

Fees and Billing

Standard rate: $150 per 50-minute session
Intake session: $200 (includes one temperament assessment)
Additional assessments: $35 each
Payment due at the beginning of each session
Payment options: Cash, check, or credit card (+$5 service fee)
NSF fee: $30
Payment plans available upon request

Canceling or Rescheduling Appointments

Cancellations must be made at least 36 hours in advance.

First missed appointment without notice: 50% charge
Additional missed appointments: Full rate charged

This policy is strictly enforced by the My Life Counsel Board of Directors.

Financial Assistance

Clients in need may apply for financial hardship assistance.Approval typically takes 24 hours but may take up to seven days.

Appointment Timing

Appointments are scheduled to minimize wait times. Sessions last 50 minutes. Clients arriving more than 15 minutes late may have their session shortened or canceled (subject to cancellation policy).

What to Expect During Your Intake Session

Introduction and Overview – Purpose and process explained
Paperwork and Consent Forms – Review and complete necessary documents
Assessment – Includes temperament (APS) and issue discussion
Personal History – Background, family, and prior counseling
Goals and Expectations – Define desired outcomes
Therapeutic Plan – Discuss frequency and approach
Questions and Clarifications – Opportunity to discuss concerns
Next Steps – Schedule follow-up and plan assignments

Termination of Counseling

Counseling may be terminated by mutual consent or by either party at any time. Missed appointments or lack of contact for two weeks may be interpreted as voluntary termination. Documentation of termination will be placed in the client’s file.

Counseling Agreement

I understand and voluntarily agree to abide by this Informed Consent Agreement as presented. I consent to participate in counseling services provided by My Life Counsel.

I release all liability against My Life Counsel, J.S. Inman, counselors, contractors, employees, or volunteers. I understand confidentiality exceptions as required by law.

I acknowledge and agree to the financial terms, cancellation policies, and payment responsibilities.

If I choose to use insurance, I understand the limitations on clergy confidentiality and My Life Counsel’s non-liability for insurance decisions.

I understand that My Life Counsel does not provide emergency services. In the event of a crisis, I will contact 911 or go to the nearest emergency room.

I consent to electronic communications for scheduling or telehealth purposes, understanding that complete security cannot be guaranteed.

If any part of this agreement is unenforceable, the remainder shall remain in effect.

By digitally signing, I acknowledge that I have read, understood, and accepted all terms stated herein.

Signature

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