Before scheduling your first session please fill out these two forms below PERSONAL DATA INTAKE FORM Name * First Name Last Name Birth Date MM DD YYYY Email * Phone * (###) ### #### City * How did you find our services? Occupation (if applicable) Occupation (If not applicable, please designate if you are a student, stay at home mother, or other) Hobbies Any important family history to be aware of? What is your current living situation? Marital Status - Please choose your current status Dating Engaged Married Separated Divorced Widowed Remarried Name of Spouse / Significant other Their Religion Any important relationship information to be aware of? Have you dealt with severe emotional struggles in your past? Yes No Have you ever had any therapy or counseling before? Yes No What was the result of your counseling? Personality Information Choose as many as apply: Acitve Ambitious Self-confident Persistant Nervous Hardworking Impatient Impulsive Moody Often-blue Excitable Imaginative Calm Serious Easy-going Shy Quiet Likeable Submissive Lonely Self-conscious Sensitive Do you have sleeping issues? Yes No Have you had suicidal ideation in the past two years? Yes No Rate your health: Very Good Good Average Declining Approximately how much sleep do you get each night? Have you had any weight changes recently? Yes No If so, what are the reasons for your weight loss/gain? List all important present or past illnesses or injuries or handicaps: How frequently do you consume alcohol? Daily Weekly Occassionally Rarely Never In the last five years, have you used illegal or excessive prescription drugs? Yes No If so, what? Have you ever been arrested? If so, what for? Have you come to the place in your spiritual life where you know with certainty that if you were to die tonight you would go to heaven? Yes No Uncertain If yes, what is the basis for answering the question as you did? Do you pray to God? Never Occasionally Often Everyday When you pray, what do you pray about? Do you consider yourself a Christian? Yes No Uncertain Denominational Preference What church do you attend? How long have you attended? Have you been baptized? How many times per month do you attend church? Are you actively involved in your church or have people you can talk to in your church? How often do you read your Bible? Do you have personal devotional time / quiet time? If so, please describe how you spend your devotion time. Have there been any recent changes in your religious /spiritual life? Please describe the current issues you are struggling with. What have you tried to do about it? What are your expectations or desires with seeking counseling? What brings you here at this time? (Did any recent event cause you to schedule the appointment now?) Is there any other information you think I should be aware of before we meet? Thank you so much for completing both forms. You will be receiving an email from me soon to schedule our first counseling session. RELEASE OF LIABILITY FORM This RELEASE and Waiver of LIABILITY is made and entered into on this date by and between Abiding Leaves Counselors and name as stated above (counselee). * MM DD YYYY As a precondition to any and all counseling/mentoring services to be provided by the counselor, the undersigned, in consideration of the services provided by the counselor, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the mentoring relationship/services as a direct or indirect result of any involvement Mentee may have with the mentor or the mentors church or any other partnering/hosting church. * I Agree Confidentiality is an important aspect of the spiritual friendship relationship, and we will carefully guard the information you entrust to us. All communications between you and our counselor will be held in strict confidence, unless you (or a parent in the case of a minor) give authorization to release this information. The exceptions to this would be: 1.) if a person expresses intent to harm himself/herself or someone else; 2.) if there is evidence or reasonable suspicion of abuse against a minor child, elder person, or dependent adult; 3.) if a subpoena or other court order is received directing the disclosure of information; 4.) if/when mentors consult with their supervision; or 5.) if a person persistently refuses to renounce a particular sin (habitual unrepentant rebellion against the Word of God) and it becomes necessary to seek the assistance of either terminating the mentoring or bring in others in the church or their family to encourage repentance, restoration, and reconciliation (Matthew 18:15-20). Please be assured that our mentors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible. * I Agree Natural Health Client Statement * I hereby attest to the following: That I am here, on this and any subsequent visit which includes Phone, virtual or email appointments, solely on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. I fully understand that Linda Noder (or affiliated Abiding Leaves Counselors) is/are not a medical doctor and I am not here for medical diagnostic or treatment procedures. The services provided by Linda Noder at Abiding Leaves Health and Wellness (or affiliated Abiding Leaves Counselors) is/are at all times restricted to education and guidance on the subject of natural health matters intended for general natural health well-being and do not involve the diagnosing, prognosticating, treatment, or prescribing of remedies for the treatment of any disease, or any licensed or controlled act which may constitute the practice of medicine in this state or province. This service is also holistic in nature and not one-on-one nutritional counseling as a State licensed nutritionist would perform. I am a Natural Health Educator and Counselor. This agreement is being signed voluntarily and not under any pressure of any kind. I Agree The counselee further understands that it is the specific intent and purpose of this legal document to release and discharge any and all claims and causes of action of any kind or nature which are directed toward a mentor, mentee, Counselor, Pastor or Church. This includes causes which are known or unknown, specifically mentioned or implied, or not mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document. The undersigned recognizes the counselor is able to stop counseling at any time due to conflict, differences in religious opinion, or for any reason the counselor deems necessary as a religious organization. The undersigned waives all right to sue or file a charge against the counselor or Abiding Leaves Health and Wellness. The undersigned further specifically waives any claims or right to assert that any cause of action or claim or demand has been, through oversight or error, intentionally or unintentionally omitted from this release. The undersigned also understands that the mentor has been trained through Women Becoming Whole, but is not state licensed and not under the regulatory authority of any governmental agency. Also, when the term mentor/counseling or counselor is mentioned above it does not refer to psychiatric or psychological state licensed professional, psychiatric, legal or clinical medical advice provider. The advice given is based on how to think rationally and clearly from a Christian Biblical perspective. The nature and source of all information given comes from the Bible along with added non-traditional health and wellness resources, and therefore is sometimes referred to as Biblical Counseling, Discipleship Counseling or Whole Health Mentoring. * I Agree I HAVE READ AND UNDERSTAND ALL OF THE ABOVE: Digital Signature First Name Last Name Date MM DD YYYY Thank you so much for completing both forms. I will reach out soon to schedule our first session.