Manchester, TN Intake Form | Beautifully Broken

Manchester

Dear Friend(s),

Thank you for trusting Beautifully Broken with your healing journey; we look forward to meeting you soon. To ensure you remain in control of your care, we do not mandate session frequency, require contracts, or keep credit card information on file.

Our specialized counselors work to resolve issues efficiently, saving you time and investment. We do not accept insurance to streamline your care, provide transparent billing, and protect your privacy. Additionally, you will have direct cell phone access to your counselor rather than communicating through a receptionist.

Please complete the form below for a faster set up experience or call or text

931–434–0046 for any other questions or needs.

Best regards,

Beautifully Broken

Partners

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I confirm I am seeking consultation for this location*

Manchester

Have you already spoken with one of our counselors?*

Yes

No

First Name*

Last Name*

Name of Spouse (for Couples Counseling)

Name of child if you are seeking help for a child. (One form per child)

Age of child

Cell Number*

May we text you at this number?*

Yes

No

Emergency Contact Name:*

Emergency Contact Number:*

Address

Email*

Which location would you like to attend?*

Confidentiality Notice: * IMPORTANT

We prioritize your privacy and will maintain confidentiality unless required by law to report child abuse, elder abuse, or potential harm to yourself or others. As pastoral counselors, we do not report care details to insurance providers.

While you may reach us via text or email for routine inquiries, please call 911 immediately if you are in a crisis. Please note that we do not mediate relationship issues outside of scheduled appointments; if you require additional support, please text your counselor to schedule a session. We remain committed to impartiality and will not take sides in relationship dynamics.

Please sign that you have read and agree to the above clause regarding confidentiality.

When is the best time to contact you?*

What days are you available for counseling sessions?*

What times are you available for counseling?*

PLEASE READ COMPLETLY BEFORE MOVING FORWARD!

*Financial Policy:

As pastoral counselors, we provide care based on biblical principles. To ensure maximum privacy and avoid insurance company interference or mandatory clinical diagnoses, we are a private pay practice and do not bill or accept insurance. We accept all major credit/debit cards, cash, checks, HSA, and FLEX. Fees are due at each session unless prior arrangements are approved by the owner.

Our standard fee is $125.00 per hour for excellent & experienced care. As experts in the field, we do not offer a sliding scale option. Sign that you have read and agree to these terms.*

No Show or Late Cancel Policy

If you continue to cancel your appointment at the last minute, you will be required to pay a $50.00 late cancel fee before making another appointment. The invoice will be sent via PayPal and no other services will be granted until that invoice is paid.

Sign that you have read and agreed to these terms.*

Faith Based with proven experience and training:

At Beautifully Broken Counseling, we are professionally trained and have chosen to be Pastoral counselors. This allows us to operate freely as Faith Based in all that we do and not be tied to the state. Although many of our Pastoral Counselors have much higher degrees and certifications than required by law in TN, we want everyone to know that we are unapologetically Faith based. We have a caring heart for anyone who comes into our family. You will find caringPastoral Counselors who will work hard with you so that you can meet your goals. We are not about Church attendance, but we are about relationship. This model has been extraordinarily successful and our reviews will attest to that truth. If we sound like a good fit for what you are looking for please sign below and submit your form. A Pastoral Counselor will be assigned to you and will reach out to you soon.

Practice Standards:

At Beautifully Broken Counseling, we are professionally trained Pastoral Counselors. Operating as a faith-based practice allows us to focus on spiritual relationships rather than state regulations or church attendance. Our counselors often hold advanced degrees and certifications exceeding state legal requirements, and our successful track record is reflected in our client reviews.

If our approach is a good fit for your goals, please sign and submit the form below. An assigned Pastoral Counselor will reach out to you soon.

Signature*

Why are you seeking Counseling?

Tenn. Code Ann. § 63-22-204(4) (part of the Licensed Professional Counselors statutes):

https://law.justia.com/codes/tennessee/title-63/chapter-22/part-2/section-63-22-204/

Manchester Intake Form

Manchester

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