CLM Forms
Initial Intake Form:

The initial intake form is the first step in setting up an appointment for individual counseling. It provides us with the basic information that is necessary to help us assign a counselor that will meet with you. The completed form can either be mailed, faxed or hand delivered prior to the initial appointment . Please complete the entire form (all 4 pages). The form should not be sent electronically - via email - since privacy and confidentiality cannot be assured. Returning the form electronically also does not allow us to comply with HIPAA regulations. Once the completed form is received you will be contacted by phone so that an initial appointment can be arranged.

Adolescent Intake Form:

If the person to be counseled is under the age of 16 we ask that the adolescent intake form be completed before the first appointment. The completed form can either be mailed or faxed prior to the initial appointment, or hand delivered at this appointment. This form can be extremely helpful for the counselor. It can give the child/teenager an opportunity to think about the questions and provide an answer without an adult sitting before them. If any difficulty is encountered with reference to completing this form please call or bring this to the counselor's attention at the first session.

Detailed Intake Form:

After you have been contacted and an initial appointment has been scheduled you will be asked to complete a long intake form. This is a confidential form that provides information that is helpful to your counselor. This form should take approximately 10-15 minutes to complete. Bring this completed form with you to your first appointment.

Christian Life Ministries
Biblical Counseling & Training
Christian Life Ministries Biblical Counseling & Training
1948 N Plaza Drive Rapid City, SD 57702 • (605) 341-5305 • clm1@rushmore.com