NDCI Couples Counseling Intake Form

1. BASIC INFORMATION

Full Name (Partner 1):

Full Name (Partner 2):

Date of Request:

Phone Number (Partner 1):

Phone Number (Partner 2):

Email Address (Partner 1):

Email Address (Partner 2):

2. PARTNER STATUS

Are you a Partner (member) of New Destiny Church International?

Yes No

If yes, how long have you been a partner?

3. TYPE OF COUNSELING REQUESTED

(Check all that apply)

Pre-marital Counseling

Marriage Restoration

Conflict Resolution

Communication Improvement

Spiritual Alignment

Other (please specify):

4. RELATIONSHIP BACKGROUND

Relationship Status:

Years Together:

Children Involved?

Yes No

Briefly describe the reason you are seeking counseling:

5. SPIRITUAL ASSESSMENT

Are both individuals saved?

Yes No One is saved

Are you both baptized?

Yes No One is baptized

Do you pray together?

Yes No Sometimes

Are you currently active in ministry? If yes, which one(s)?

6. SCHEDULING PREFERENCES

Preferred Days/Times for Counseling:

Are you open to virtual counseling sessions?

Yes No Prefer in-person but open to virtual

7. ACKNOWLEDGMENT

Confidentiality and Christian Counseling Expectations:

We understand that all counseling sessions are confidential and will be conducted according to biblical principles and Christian values. We acknowledge that our counselors are trained to provide biblical guidance and support for our relationship. We commit to participating honestly and openly in the counseling process, understanding that growth and healing require transparency and a willingness to apply biblical principles to our relationship.

We understand that counseling is a process that requires time, commitment, and the grace of God. We agree to attend scheduled sessions regularly and to complete any assignments or homework given by our counselor. We also understand that in cases where there may be danger to ourselves or others, confidentiality may need to be broken in accordance with legal and ethical guidelines.

By signing below, we acknowledge that we have read, understood, and agree to the terms outlined in this intake form.

Partner 1 Signature

Date: _______________

Partner 2 Signature

Date: _______________

FOR COUNSELOR USE ONLY

Initial Assessment Notes:

Assigned Counselor: ______________________ Date: __________

First Session Scheduled: ______________________ Time: __________

New Destiny Church International | Couples Counseling Ministry

For questions or concerns, please contact the church office.

Address

Sunday Service

Bible Study

NDCI App by MinistryBrands Amplify

Get the Latest News Via Email

Add your "Form" element below.