Pace Intake Form

Pace, FL Location

Please NOTE: Beautifully Broken Counseling never mandates how often you need to come to counseling. We never set up contracts or keep CC information on file. We understand in these difficult times that you need to be in charge. We are only here to help and will never waste your time or investment. Our counselors are specialists with high reviews. Therefore, they will strive to get to the heart of the issue as quickly as you allow. This saves you time, money and the pain of starting over again with another counselor. You will also have access to your counselors cell phone for your connection. We do not use a receptionist for your added privacy. Thank you for trusting us with yourself or your family. We are here to serve in an amazing journey of healing. We look forward to meeting you soon.

Contact Us

I Confirm I am seeking counseling for the Pace, FL location*

Yes

Please Acknowledge You Have Read The Above Notice By Initialing Below*

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: * IMPORTANT

We will strive to always keep your confidences. However, if you report child abuse, elder abuse, and dangerous bodily harm of self or others, we are mandated reporters. Therefore, we are bound by the law to make an official report. Unless these factors are present, your information remains your information and private. As pastoral counselors, you will have the added confidentiality as we do not report to your insurance regarding your care. You can always send us a text or email and we will get back to you as soon as possible. But if you are in serious trouble, please call 911 for emergency care. We are unavailable to “referee” for your relationships outside your appointment time. If you find that you need more attention, you may text your Pastoral Counselor to set up an agreed upon time to meet. We strive to be impartial and will attend to both sides of your relationship and will not engage in taking sides.

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!

*Billing Fees and Policies:

As pastoral counselors, we serve our clients with compassionate and excellent care according to biblically based principles. Many of our clients stay in touch and will reach back out when life brings a new challenge. To ensure we serve our clients with the utmost privacy and confidentiality without interference from insurance companies, we are a PRIVATE PAY practice. We accept all major credit/debit cards, cash, or checks including HSA and FLEX. We DO NOT BILL OR ACCEPT INSURANCE. We strive to minister to each person according to each situation. It is best to do so without potential interference or discussions with an insurance company. We will never label you with a clinical diagnosis as required for insurance reimbursement which may cause you difficulties later. You will only deal with our pastoral counselors in almost every part of the process, giving you added confidentiality. We have a great track record for helping people and have more than 100 years of combined experience amongst our pastoral counselors. This means that your investment in yourself will be well rewarded. Please remember that we DO NOT BILL OR ACCEPT INSURANCE. We ask that the fee is paid at each session unless other arrangements have been discussed and approved in advance.

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. In the state of TN, this requires a master’s degree, Seminary and an ordination or commissioning. 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.

Signature*

Why are you seeking Counseling?