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LIVING WATER COUNSELING

Randy Young, LLC

WHO WE ARE

Living Water Counseling Ministry has been a vital part of this community since 2004. We
are dedicated to Jesus Christ, who is the Living Water, and desire to meet the mental,
emotional, and spiritual needs of people as they grow in grace and Christ-likeness.
Living Water Counseling seeks to provide help to the Christian community and as an
outreach to all who want biblical guidance. We base our counseling on the principles of
Gods Word, the Bible. We pray for our counselees, employ our gifts, skills, and training
to the best of our ability, and understand that all is ultimately dependent upon the work
of the Holy Spirit. As counselors we are here to walk alongside, to hear, encourage and
support people through their various trials. We will help identify the roots of issues,
explore how they have impacted their own and other peoples lives, and help to replace
sinful patterns with new approaches that are grounded in wisdom from scripture.

THINGS TO REMEMBER
1. Because of the number of people requesting counseling, there may be a waiting list.
You will be called on a first come, first serve basis. Be sure to give us the BEST
number to reach you.

2. All information will be held confidential, with the exception of the counselor
determining a threat of physical harm to you or another person. This type of concern
must be dealt with in a protective manner, possibly involving the authorities who
govern these matters in our state.
3. If child abuse is discovered, the counselee will be advised of the biblical admonitions,
encouraged to do that which is right, and informed that the governing authorities of
the state must be notified.
4. If, during the course of counseling, the counselor discovers or determines that there is
continual unrepentant sin involved in the life of the counselee, or a serious violation of
the civil or criminal law, then appropriate biblical discipline will be followed as outlined
in the scripture, unless otherwise directed by the counselees church or by a criminal
court of appropriate jurisdiction. Under these circumstances, Living Water may need
to release information regarding your counseling to others.
PERSONAL DATA
Name______________________________________ Ph: (____)_________________Cell:
(___)__________________ How did you hear about us?
______________________________________________________________________
Address__________________________________________________________________________________________
Email____________________________________________________________________________________________
Occupation_______________________________________ Employer_____________________________________

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Years of Education_____________ Type of Certification or
Degree____________________________________
Sex: male female Birth Date __________________________
Age___________________________

Military Service: Yes No Branch: _____________ Combat: Yes No Dates:


__________________
Are you . . . Single Engaged Married Widowed Separated Divorced
If married, how long? ____________ Spouses Name__________________________
_____Age______________
Spouses Years of Education ___________ Spouses Certification(s) or
Degree(s)______________________
Spouses Occupation______________________________ Spouses Employer:
___________________________
If divorced, how many times? __________ Date(s)____________________________
Reason(s)_____________
__________________________________________________________________________________________________
Were you Christian at the time? Yes No

Has your spouse ever been divorced? YesNo If yes, how many times?
_________________________
When was last divorce?
___________________________________________________________________________
How long was he/she married to previous
spouse(s)_______________________________________________
What was the reason(s) for the divorce(s)?
_________________________________________________________

Is spouse willing to come for counseling? Yes No


If not, please explain the reason as you understand
it______________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Have you ever been separated? Yes No If yes, when? _____________ For How Long?
____________
What were the circumstances surrounding the separation?
_________________________________________
__________________________________________________________________________________________________
________________________________________________________________________________________________

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FAMILY DATA
Do you have children? Yes No If so, how many?
_______________________________________________

Are any of your children step-children? Yes No If so, how many?


______________________________

Are any of your children adopted? Yes No If so, how many?


___________________________________

Are any of your children foster children? Yes No If so, how many?
_____________________________

Have you had any miscarriages? Yes No If so, how many?


_____________________________________

Have you had any abortions? Yes No If so, how many?


________________________________________
How old were you at the time(s) the abortions occurred?
___________________________________________
__________________________________________________________________________________________________
Is your current spouse the father/mother of all of your children? Yes No If no, please state
names of parent(s) as you list their names below.
Please list names, ages, and sex of each of your children:
_________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Special Needs Information


Does anyone in your family have special needs or physical disabilities? Yes No
If yes, please describe
briefly______________________________________________________________________
__________________________________________________________________________________________________

Does the person with special needs have a regular care giver? Yes No
Does the Primary Care Giver have Respite Care? Yes No
Is your family connected with any support groups in the community? Yes No If yes, what
group(s)?____________________________________________________________________________
_________________________________________________________________________________________

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Spiritual & Religious

Do you believe in God? Yes No Are you a born again Christian? Yes No
Does your spouse believe in God? Yes No Is your spouse a Christian? Yes No
Your denominational preference (if any)
___________________________________________________________

Are you attending church regularly? Yes No


If so, please give name of
Church_________________________________________________________________
How long attending? ________________ ____________________________________________________________
Does your spouse attend the same Church? Yes No
If not, please give name of his/her
Church_________________________________________________________

Did you ever receive baptism? Yes No If yes, when?


___________________________________________
How often do you pray?
__________________________________________________________________________
How often do you read the Bible?
_________________________________________________________________
Who is Jesus to you? _____________________________________________________________________________

Reason(s) for coming to Living Water Counseling


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

INSURANCE BILLING
Because we are a faith-based ministry, it is uncommon that we will be able to receive payments
from your insurance company. If you would like to pursue this option, you will need to contact
your insurance company to inquire if they will cover faith-based counseling from a non-licensed
professional. If they are willing to pay, we will need a copy of your insurance card. You may also
be able to use your Health Savings Plan as a means of payment for counseling. You will be

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responsible for payment until we can ascertain if your insurance company is willing to work with
Living Water.
CLIENT ACCEPTANCE
By accepting counseling from Living Waters counselors, the counselee agrees to the following
provisions: (please initial each bullet point).

In order to provide ministry in the most effective manner, we ask that you attend all
scheduled appointments, or notify the office staff 24 hours in advance if you must cancel.
There will be a $35 no show fee if you do not notify us 24 hours ahead of your scheduled
appointment time. ___________ (initial)
Living Water believes it is beneficial to both you and your counselor to commit to a
minimum of four sessions. However, if after the first session, you dont believe the
counselor is the best person to help you, please let your counselor or the office staff know.
We will be happy to schedule you with another counselor at Living Water, or provide you
with a list of counselors within the community. ___________ (initial)

In the event of a dispute, charge, claim or other controversy, against or involving Living
Water Counseling Ministry or its staff, I agree to pursue mediation in accordance with the
biblical principles set forth in Matthew 18:15-17 and 1Corinthians 6:1-8. Therefore, I
agree, first, to address the grievance with the offending party, one on one. If the
grievance is not resolved, then I will have my dispute, charge, claim, or other controversy
heard before a designated director from Living Water Counseling Ministry. If still
unresolved, I will go to him or her with two other Christians (preferably church leaders),
along with the designated director from Living Water Counseling. If reconciliation is still not
forthcoming, I then agree to pursue mediation in accordance with guidelines set forth by
Peacemaker Ministries. I will not pursue civil litigation against Living Water or its staff, but
will honor the biblical exhortation to settle grievances in the church of Jesus Christ, unless
a criminal offense has been committed against me or my family. __________ (initial).

In some circumstances, your counselor may recommend recording the session


electronically. Please indicate whether you agree to video and audio recording for
counseling and supervision purposes. _______Yes (initial) _______No (initial)

By signing below, you are agreeing that you have read and understood the previous two pages,
and are in agreement.

_______________________________________________________________ ____________________
Signature Date

________________________________________________________________________ ______________________
Name (please print) Phone No.

**If you are considering having your children seen by one of our counselors, please
complete section below. You must have legal custody in order to sign for a minor to
receive counseling.

I, the undersigned, have read, fully understand, and agree to the above provisions for myself
and/or as guardian for the children named below, if they have contact with the counselor.

___________________________________________________________________ _____________________
Signature of Parent who has legal custody of children named below Date

___________________________________________________________________
Printed Name of Parent who has legal custody of children named below
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_______________________________________________________________ _____ ____________________
Name of child to be seen by Counselor (please print) Date of Birth

_______________________________________________________________ _____ ____________________


Name of child to be seen by Counselor (please print) Date of Birth

___________________________________________________________________ ____________________
Name of child to be seen by Counselor (please print) Date of Birth

___________________________________________________________________ _____________________
Name of child to be seen by Counselor (please print) Date of Birth

_______________________________________________________________ _____ ____________________


Name of child to be seen by Counselor (please print) Date of Birth

___________________________________________________________________ ____________________
Name of child to be seen by Counselor (please print) Date of Birth

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