• Instructions for Filling out this Form

1. Please take a minute and fill out the questions below by clicking on the space and typing your answer.
2. Then, press the Send Form button at the bottom of the page.

Your answers to the following questions will be helpful in planning my responses for you. Please answer each item carefully. The information you provide here is absolutely confidential! Your answers are privacy protected by our hard encryption program called PGP. What is PGP?

• Personal Information:

Age

Please enter your complete e-mail address

Today's Date (MM/DD/YY)

Nickname/Name you want to be called (8 characters maximum)

How did you learn about The Prayer Counseling Center?

What search engine did you use?

What keywords did you use?

Does anyone else have access to your e-mail address?
Yes No

What made you pick Prophet Ricky Dent to contact?

• For Billing and Emergency Purposes Only:

City

State

Zip

Home Phone

Work Phone

What Judgements or Inner Vows have you made towards your parents? example: (I will never be like them ...)

What areas of your life do you feel you need prayer counseling / Inner healing in and why?

What specific things do you want to see change in your life? Do you have a specific question for a counselor?

Have your ever received psychiatric or psychological help or counseling of any kind before?
Yes No
If "Yes", please explain.

Are you on any antipsychotic, antidepressant, or anti-anxiety medications?
Yes No
If "Yes", please list, with dosages:

Are you taking any other medications?
Yes No
If "Yes", please list, with dosages:

• Living Arrangements

Name of Church (If Applicable)

Relationship Status:
Single
Married
Divorced
Committed Relationship

Living Arrangement:
Alone
With Roommate
With Spouse
With Family

• Occupational Information:

Do you enjoy your job?
Yes No

• Type of Response:

If you have any serious thoughts about committing suicide, online consults are not appropriate for you at this time. Please stop and call your local suicide hotline by dialing 911.

• Important Information:

A hard copy of the agreement is needed for our records, please mail or fax a copy of this agreement with your signature.

Confidentiality:

Interactions between client and counselor are confidential. Unless I have permission, I will not discuss anything that transpires between us with anyone. There are three major exceptions to confidentiality this includes but is not limited to: South Carolnia Law requires all mental health professionals to report:

1. Incidences of child or elder abuse.
2. Intent to commit suicide.
3. Threats to do harm to yourself or another person.

While it is my legal responsibility to report any of the above incidents, it is also my personal and ethical responsibility to help you find a therapist in your area should such thoughts occur.

We will put forth all effort to help you in the shortest amount of time.

Congratulations on having the courage to take this important step.