PAPERWORK


Please complete this form at least 24 hours before your appointment.
Date:
Name:
Birthdate:
Address:
Home Phone:
Cell Phone:
Work Phone:
Email:
Emergency Contact:
Phone:
Marital Status: Married Divorced Single
Spouse Name:
List Children and Ages:
List Siblings and Ages:
Reason for Consultation:
Mental Health History:
Prescription Drug Usage:
Physical Ailments:
Describe Spiritual Journey:
  Describe Your Childhood:
  Have you any childhood traumas:
  Anything you would like to add:
I have no suicidal thoughts:
I battle suicidal thoughts:
 I know how I would do it:
I have attempted suicide:






Please read the following and answer agreement below:

INFORMED CONSENT

Credentials:    Kim Herum has an M.A. Degrees in Urban Ministry Studies majoring in both Pastoral Counseling, and Marriage and Family Therapy.  She is not a Licensed Professional Counselor but has chosen to minister as a healing prayer minister and is not licensed.  She may make reference to the written word of God and always includes prayer in her ministry.


Services Explained:    Before entering into any type of care, it is important that you gain an understanding of the types of care provided, the risks, and the potential benefits. A web site by Kim Herum has been provided which contains the basic philosophy, goals, and methods of the care offered. This type of ministry is life changing and comes with many emotions and reactions to those emotions. As a result of this ministry, you may experience unwanted feelings such as: sadness, guilt, anger and anxiousness that had been previously repressed. You are responsible to keep Kim aware of those feelings, thoughts and behaviors relevant to care, especially thoughts of harm to yourself or anyone else. You may handle relationships differently than you have in the past. You may make a number of alterations to your life. You understand that Kim does not make any decisions for you but is there to allow you to process and assist you in understanding the impact of your decisions. 


Logistics:   Appointments can be arranged by phone, 205-267-9382.   If you need to cancel, please do so as soon as possible.  If you are running late, please call.  There is no childcare provided and children may not be brought along.  A free-will donation would be gladly accepted.  Termination of Services can occur any time you desire, though it would be best to meet and bring closure to our time together and discuss your future plans. 


Confidentiality:  All conversations are held in confidence with few exceptions.  State law, federal regulations and our code of ethics specifically guarantee this confidentiality at all times except in the following cases:

1. State law requires notification of appropriate persons or agencies if the care minister believes a client is in eminent danger of harming himself or herself or another person.

2. State law requires that the care minister report all suspected incidents or admissions of child, elderly or spousal abuse. The information must be given to the proper county agency that intervenes in this type of situation.

3. State and Federal law require that if subpoena is issued by a court of law, the care minister must respond, however, this is not a counseling practice but a prayer ministry and we will have no records to provide. 

4. Our ministry is conducted under the general guidance and accountability of a mentor and/or prayer partner and if necessary may need to be discussed without disclosing details or identity.

5.  Information give by one spouse in marriage mentoring will not be kept secret, from the other spouse if it is not in the best interest of both parties.


LEGAL AGREEMENT

I understand, consent to, and have provided honest answers to the above information and questions.

I understand that Kim will attempt to assist me (us) in developing a plan, and that she does not make any representations or warranties with respect to the results of her services and/or referrals or her ability to help me (us) with my (our) credit/financial/emotional/spiritual management.

I further understand and acknowledge that Kim will not allow the undersigned to participate in this activity without releasing and holding harmless Kim, and Council of God Ministries.  Further, the undersigned requests that Kim allow them to participate in this activity, and in consideration thereof agree to indemnify, hold harmless, release and forever discharge Kim Herum, and Council of God Ministries from all actions, causes of actions, claims, damages, costs, expenses or damages of any kind growing out of or related to any activity in which the undersigned participates.  The undersigned further acknowledges that this is a full and complete release for all injuries and damages, which the undersigned may sustain as a result of the undersigned participation in these services.
I agree with the above: