Initial Background Information

Participant Name

Date

Month

Day

Year

Notice of Confidentiality:

I am dedicated to preserving the confidentiality and privacy of all my participants. Any information provided will be held in strict confidence. Please know that some state and federal laws require that I disclose information in the following situations:

If I suspect a child, elderly, or disabled person is being abused or neglected, I am required to report that information to a state agency.
When I believe a client is a danger to themselves or others (suicidal or homicidal).

To better serve and pray for our upcoming appointment, please answer the following questions to the best of your ability.

1. How did you find Foxfire Ministries or me?

Online website

Referral

Other

______________________________

2. If applicable, please describe your personal relationship with Jesus Christ.

3. Briefly describe what has precipitated your desire to seek ministry support.

I choose to discuss my needs during our scheduled appointment.

Signature

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