Intake Form

Thanks for getting in touch with me at Christian Counselling Sydney (CCS).

To help me provide the best service I can for you, it would be helpful to know some more about you and your situation.

I have some standard intake questions below to help me get to know you and to help us work out suitable appointment times going forward.

Please feel free to ask any questions that you have. (See the Contact page.)

Thanks, Jeremy
Christian Counsellor

It’s up to you how much you are comfortable to say at this stage and we understand that you may prefer to not say much yet.

Please be assured that the information you share here is used only respond to your request for help and is kept private and confidential. (This website uses an SSL certificate to encrypt data shared between your web browser and the CCS web server.)

Intake Form

First Name

Last Name

Date of birth

Phone Number

Email Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Reason for counselling (i.e. What would you like to focus on in counselling? What are your specific goals?):

Usually, the counselling process will involve a minimum of 2–3 appointments to gain a clear understanding of the issue and to start making progress on your goals. Very occasionally someone might be after specific tools and a single session can be enough to start the change process. At this stage, how many sessions are you expecting you might have?

1 only

2–3

4 or more

I’m not sure but I’m open to as many as necessary

During 2024 Jeremy has the opportunity to help a student gain experience in biblical counselling. Would you be open to having a student sit in on your counselling sessions to watch/observe? (There is no obligation to say yes.)

Yes, I’m open to having a student sit in on my counselling sessions

No thanks, I’d prefer not to have a student sit in

If meeting in person, do you have any accessibility requirements? (I.e. there’s an alternative entry door that can be opened if steps are difficult or you need to use a walker or wheelchair.)

Do you have any current involvement with a local church? If so, what church are you involved with? (Optional)

Do you have any previous counselling experiences? If so, who have you seen in the past (i.e. person/service)? (Optional)

Other people who are, or have been, involved in helping (optional):

Intake Form

Are you ready to flourish as God intends?

Let’s be friends!