New Clients – Kairos Christian Counseling

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New Clients
Get in Touch

Home
About
Services
New Clients
Get in Touch

New Clients

We make it super easy!

Download the forms below

Print the forms

Add your “John Hancock”

Bring to 1st Appointment

Download Consent Form

Download Consent Form Signoff

Download TeleHealth Consent Form

Download Privacy Practices

Download Privacy Practices Signoff

If you desire anyone to be aware of your counseling, please complete form and bring to first session. Only one person/entity per form.

Download Release of Information

Please fill out this form so we can better assist you

Full Name*
Email*
Date of Birth*
Age*
Address*
Street Address City State ZIP Code
Home Phone Number
Is it okay to leave a message?
- Yes
- No
hidden
Cell Phone Number
Is it okay to leave a message?
- Yes
- No
Is it okay to text?
- Yes
- No
Texting Disclaimer*
I understand this disclaimer.
Texting will only be used to confirm or cancel appointments as it is not the most safe and confidential way to communicate. By checking "yes" you're stating that you're aware of the risks and agree to this manner of communicating.
Work Phone Number
Is it okay to leave a message?
- Yes
- No
What is your marital status?*
Spouse Name
Children's Names & Ages
Do you have insurance that covers mental health?
- Yes
- No
Who is your insurance provider?*
Is this your primary insurance?
- Yes
- No
What type of counseling are you seeking?*
- Individual Counseling
- Couples Counseling
- Family Counseling
Reason for seeking counseling*
Scheduling Preference*

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