Secure Intake Form For Counseling and Coaching

These services are intended for cross-cultural workers who have lived abroad for at least six months. If you are unsure of which service you need, fill out this form and we can help you determine what would be most helpful for you. *If you request marriage counseling, each spouse should fill out a request form individually. Be advised: This is an extensive form and may take at least thirty minutes to fill out, and cannot be saved. For more information, please contact us via our website.

General Information

Your first and last name:

Date of birth:

Month

Day

Year

Country of current service:

How long have you lived in your current country of service?

Current overseas address: (include city, state, country)

May we contact you at this number?

Yes

May we contact you via this email?

Yes

Additional ways you prefer to be contacted? (WhatsApp, etc.)

If applicable: Spouse's Name:

Children's Names and Ages:

Emergency contact name:

Emergency contact phone number:

Emergency contact email:

Local emergency contact name:

Local emergency contact phone number:

Local emergency contact email:

Current Situation

If you are currently in the U.S., what state are you in?

How long are you in the US?

Reason you are in the US:

Furlough/Home assignment

Finished overseas service

Other

If you answered other in the question above, please state your reason below:

List other countries you have lived in and how long:

Personal History

Where were you born?

How long did you live there?

What ethnicity do you identify with?

Describe any current medical issues:

Describe any past medical issues:

List current medications; Include dosage and reason for medication:

If you have ever been hospitalized for a physical illness, describe here:

Describe any other medical information that would be important for us to know:

If you drink alcohol, describe how often:

If you use recreational drugs, describe what kind and how often:

Mental Health History

*If you request marriage counseling, each spouse should fill out a request form individually.

Service being requested:

Support Coaching

Lay Counseling

Marriage Counseling

Mental Health Counseling

Other issues not listed above:

Click any boxes that apply to you:

Have you had thoughts of hurting yourself?

Past

Recently

Never experienced

Have you intentionally hurt yourself?

Past

Recently

Never experienced

Have you had thoughts of committing suicide?

Past

Recently

Never experienced

Have you attempted to commit suicide?

Past

Recently

Never experienced

Have you had thoughts of harming someone?

Past

Recently

Never experienced

Have you attempted to harm someone?

Past

Recently

Never experienced

Other choice not listed above:

Describe the problems you are having and when they began:

What do you hope to accomplish through our services?

Have you ever been seen by a mental health professional? (therapist, coach, counselor, psychiatrist, psychologist, etc.)

Yes

If yes, list all previous mental health treatment, the provider, and reason for the treatment:

List any mental health diagnoses and related medications:

If you have ever been hospitalized for a mental illness, describe here:

If you have ever experienced any traumatic events, describe here:

If you have ever experienced any emergency evacuations, describe here:

Describe any mental health problems in your extended biological family:

List your siblings' names and ages:

If your family moved often, please describe:

Describe your current relationship with your father:

Describe your current relationship with your mother:

Describe any significant events in your family history:

Describe any significant conflicts you have had with family members:

Whom do you currently rely on for emotional support?

List any other information about your family that is important:

Occupational History

What is your current position at work?

How long have you worked there?

What job stressors are you experiencing?

Informed Consent

This form is to document that I give my permission and consent to Compass Care to provide therapeutic support and treatment. While I expect benefits from this process, I fully understand that such results depend upon my cooperation. I understand that Compass Care is supervised by a Licensed Mental Health Counselor, but I may be working directly with Compass Care Staff which includes Support Coaches, Counselors, and Interns. Out of respect for the Compass Care Staff, I will notify them 24 hours ahead of time if I cannot attend an appointment or need to make a scheduling change. If I decide to discontinue services then I will notify Compass Care Staff in a timely manner. If I do not respond to my Care Staff after two attempts are made to contact me over a span of a month, then Compass Care may assume that I do not want to continue services and they will no longer be responsible for my care. I understand that Compass Care does not provide emergency services and in such an event I should call 911 or other emergency services. I agree to participate voluntarily in the care of Compass Care.

Your Signature

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Confidentiality Agreement

I understand that the content of my conversations with the Compass Care Team will be confidential. Information about me cannot be shared with another party without written consent. I understand that in order to provide quality care, general client situations are discussed in staff supervision meetings. The Compass Care Team is supervised by the Compass Care Clinical Director, who is a Licensed Mental Health Counselor and bound by the laws and ethics of the state of Florida. Exceptions to confidentiality are as follows:

1. When a client discloses intentions or a plan to harm themselves or someone else, the Compass Care Team is required to warn the victim, notify emergency contacts/family members in order to ensure safety, and notify legal authorities when necessary.

2. If a client suggests that a child or vulnerable adult is currently being abused, has been abused in the recent past, or is in danger of abuse, the Compass Care Team is required to report this information to the appropriate social service and/or legal authorities.

I understand and agree to this Confidentiality Agreement.

Your Signature

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Consent for Health Care Information

This form gives Compass Care permission to use and/or disclose protected health care information for the purpose of treatment, payment, and health care operations within Compass Care.

In order for Compass Care to provide services to you, to maintain payment records, and to conduct our normal health care operations, we need your consent. This consent gives Compass Care permission to access your protected health information as needed. It does not allow us to release any protected health care information to any person or organization outside of Compass Care, except for those we have hired to help us conduct our work (these organizations will be called business associates), or when legally mandated by law. You may revoke this consent at any time by notifying us in writing. You cannot, however, revoke any action we may have taken to disclose your protected healthcare information before you revoked your consent.

You have the right to request in writing that we restrict the manner in which your protected health information is used or disclosed to carry out treatment, payment, or healthcare operations. We are not required, however, to agree to such requested restrictions. If, however, we agree to the requested restriction, Compass Care will honor the request and it will be binding, from this point forward.

I hereby consent to the use and disclosure by Compass Care and its business associates of my protected health information for purposes of treatment, payment, and healthcare operations.

Your Signature

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Fees for Services

Compass Care strives to provide quality care for cross-cultural workers at reduced costs. Click the box which indicates the service that you are requesting.

- Cost of Coaching per Session: $75.

o You pay: Nothing. This is offered as a free service for a maximum of six months.

- Cost of Lay Counseling per Session: $100.

o You pay: $30.

- Cost of Mental Health Counseling with a Licensed Counselor per session: $150.

o You pay: $50.

Options for payment:

If you are unable to pay for services, please ask your company to pay for your Compass Care services on your behalf. If you are still unable to pay for services, then contact us on our website and request the application form for the Paul Hazlett Memorial Scholarship Fund. The Scholarship Fund is limited and may only cover a portion of the cost.

Pay in full using this link.

Ask your church, donors, or agency to pay for all or a portion of your services.

Fill out the Paul Hazlett Memorial Fund Scholarship Form (link) to be considered for further discounted rates.)

At Compass Care, we do not want any cross-cultural workers to go without needed support because of financial hardships or limitations. Please contact us on our website to discuss your financial options.

Choose your service

Coaching.

Lay Counseling (Individual or Couples).

Mental Health Counseling (Individual or Couples).

Unsure. I would like to speak with a Care Team Member to determine which service best meets my needs.

Your Signature

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Notice of Privacy Practices

Effective Date: September 1, 2025

Our Commitment to Your Privacy

Compass Ministries is committed to protecting your health information. We are required by law (HIPAA) to keep your health information private, provide you with this Notice of our legal duties and privacy practices, and follow the terms of the Notice currently in effect.

How We May Use and Disclose Your Information

We may use and share your health information for the following reasons:

Treatment – To provide, coordinate, or manage your counseling and related services.
Payment – To bill and collect payment for services provided to you.
Healthcare Operations – To support daily business activities.
Required by Law – When required by federal, state, or local law.
Public Health and Safety – To prevent or reduce serious threats to health and safety.
Health Oversight – For audits, investigations, inspections, and compliance.
Legal Proceedings – In response to a court or administrative order.
Law Enforcement – When required by law.
Coroners, Medical Examiners, and Funeral Directors – As necessary.
Specialized Government Functions – For military, national security, or correctional purposes.
Business Associates – With outside organizations under strict agreements.

Your Rights Regarding Your Health Information

You have the right to:

Access Your Records – Request to see or get a copy of your health information.
Request an Amendment – Ask us to correct or update information.
Request Restrictions – Ask us not to share certain information.
Request Confidential Communications – Ask that we contact you in a specific way.
Receive an Accounting of Disclosures – Request a list of certain disclosures.
Receive a Paper Copy of This Notice – Request a paper copy at any time.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We must notify you promptly if a breach occurs that may compromise your information. We will not use or share your information other than as described here unless you give us written permission. If you do give permission, you may revoke it at any time.

Changes to This Notice

We reserve the right to change this Notice at any time. The updated Notice will be posted in our office and on our website (if applicable).

Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

Our Office:

Compass Ministries

1214 West Bearss Ave, Tampa, FL 33613

813-374-3915

info@compass-ministries.org

Or with the U.S. Department of Health and Human Services (HHS), Office for Civil Rights. We will not retaliate against you for filing a complaint.

Contact

For questions about this Notice or your privacy rights, contact:

Privacy Officer

Roni Lacuesta

813-374-3915

Roni@compass-ministries.org

These privacy practices can be accessed on our website: compass-ministries.net

We require a signature below in order to provide service. By signing below, I acknowledge that I received and read the Notice of Privacy Practices.

Your Signature

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