Ark Christian Counseling Center – Internal Request

Date

Time:

Staff Member (First & Last Name):

Contact Type:

Phone Call

Walk-up

Other

Other Details:

CLIENT INFORMATION

Full Name(Required)

First Last

Date of Birth

Age

Gender

Male

Female

Primary Phone(Required)

Email Address

Preferred Method of Contact

May we leave a message / text?

CONNECTION TO THE ARK & SCHEDULING PRIORITY

Check the highest-priority category that applies. Use this to guide scheduling order.

CONNECTION TO THE ARK & SCHEDULING PRIORITY

Currently in the Transformational Living program (highest priority — counseling is free)

Currently participating in another Ark program

Employee or key volunteer of The Ark

Walk-up / community member specifically seeking counseling

Other / unsure:

Other/unsure Details:

INITIAL TRIAGE — CRISIS OR PRAYER SUPPORT?

Ask gently: “Is what you’re facing currently interrupting or derailing your daily life, or are you mainly looking for prayer and encouragement right now?”

INITIAL TRIAGE — CRISIS OR PRAYER SUPPORT?

Crisis / life-disrupting — needs counseling (lives significantly interrupted, family falling apart, major loss, etc.)

Primarily needs prayer, encouragement, or spiritual support — refer to Prayer Team

Unsure

Unsure — note details below for Clinical Director review

GENERAL NATURE OF CONCERN (No deep details needed)

Record only a brief, general description in the caller’s own words. Examples: “Loss of a spouse,” “Marriage is struggling,” “Family is falling apart,” “Overwhelmed by anxiety,” “Need help after a major life change.”

GENERAL NATURE OF CONCERN

FEE & APS INFORMATION SHARED WITH CALLER

Receptionist should communicate the following clearly: • Transformational Living clients: counseling is provided at no charge. • All others: sliding-scale fee based on income status (details provided at intake). • Recommended donation of $30 to cover the Arno Profile System (APS) temperament report.

Information explained to caller?

Yes

Notes:

RECEPTIONIST ACTION / NEXT STEPS:

RECEPTIONIST ACTION / NEXT STEPS

Referred to Prayer Team

Forwarded to Clinical Director / Counselor for follow-up scheduling

Other:

Other Details:

Receptionist / Client Care Host Signature:

First Last

Sign your name as an acknowledgment of submission.

Date Signed:

INTERNAL USE ONLY • No One Walks Alone

Uniting hands

Disaster Response

Ark Warehouse

Agape Community Clinic

Ark Commissary

Healing hearts

Transformational Living

transforming communities

Uniting Churches

Community-Wide Worship Events

Foster Care Task Force

Hunger Alliance

Trust Initiative

Internal Request

CLIENT INFORMATION

CONNECTION TO THE ARK & SCHEDULING PRIORITY

INITIAL TRIAGE — CRISIS OR PRAYER SUPPORT?

GENERAL NATURE OF CONCERN (No deep details needed)

FEE & APS INFORMATION SHARED WITH CALLER

RECEPTIONIST ACTION / NEXT STEPS:

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Laura Estes

Director of Operations