RAPHA CENTER CLIENT INTAKE FORM

“Helping people renew their minds, heal from their past, and walk in freedom through Christ’s truth, love, and power.”

Preferred Method of Contact

How did you hear about the Rapha Center?

What brought you to the Rapha Center at this time?

I need someone to talk with Prayer/support Spiritual growth or discipleship Grief or loss Marriage/relationship concerns Family concerns Trauma or past experiences Anxiety, fear, or feeling overwhelmed Forgiveness or unresolved issues Identity/self-worth Life transition or major decision Struggling in my relationship with God Repeated patterns of behaviors I want to change I feel spiritually stuck I am seeking freedom from something that has been affecting my life Other

In your own words, what would you like help with?

How long has this been affecting you?

WHAT ARE YOU HOPING TO RECEIVE?

What would you most like to happen through meeting with someone at Rapha?

What would you consider a helpful outcome from this ministry?

3. CURRENT LIFE CIRCUMSTANCES

Are there circumstances currently creating significant stress?

Family Marriage/relationship Work Finances Housing Grief/loss Spiritual concerns Major life transition Conflict Other

Please briefly describe what is currently happening

4. Personal & Spiritual Background

How would you describe your current relationship with Jesus Christ?

Are you currently connected with a church?

Yes No

Are you currently involved in any of the following?

Bible Study Small Group Discipleship Prayer Ministry Church Ministry/service Pastoral Care None Currently

Is there a pastor, church leader, or trusted spiritual mentor involved in supporting you?

Yes No

Have you previously received counseling, pastoral care, or other supportive services?

Yes No Prefer not to answer

If yes, please tell us what type:

Pastoral Counseling Lay Counseling Professional Counseling Marriage/family Counseling Grief Support Trauma Support Other

Is there anything from previous counseling/support that would be helpful for us to know?

Medical & Mental Health History

Date of Last Physical Exam:

Name of Primary Care Provider (optional):

Do you currently have any medical conditions or significant health concerns?

Yes No

If yes, please describe:

Past Medical History

Please list any significant past or current medical conditions, surgeries, hospitalizations, or ongoing health concerns that may be important for us to know:

Are you currently taking any medications?

Yes No

If yes, please list medications and what they are prescribed for.

Mental Health History

Have you ever been diagnosed with a mental health condition?

Yes No I prefer not to answer

If yes, please list any past or current diagnosis(es), if known:

Are you currently receiving care from a mental health professional?

Yes No

Is there anything else regarding your physical, emotional, or mental health that you believe would be helpful for us to know?

6. AREAS WHERE YOU WOULD LIKE SUPPORT

Please check any areas you would like to discuss.

Grief/loss Trauma/past experiences Family relationships Marriage/relationships Parenting/family concerns Forgiveness Anger Fear/Anxiety Shame/guilt Self-worth/identity Boundaries Life transitions Spiritual growth Prayer Hearing/understanding God's direction Discipleship Repeated unhealthy patterns Spiritual oppression/distress Other

If Other, please explain

Is there anything you would like us to consider when matching you with someone?

Male Female No preference

Prefer someone with a particular area of experience?

Yes No

Is there anything else you would like us to know before your first meeting?

RAPHA CENTER CLIENT INTAKE FORM

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