Jan Stambaugh

Jan Stambaugh Grief Counselor

My name is Jan Stambaugh. For the past 20 years I have been working to bring healing and hope to women who are hurting, broken, and stuck. Regardless of whether the circumstance is trauma, difficult relationships, loss, or other impactful events, I am committed to helping women move forward as victors, rather than victims. I have a passionate desire for women to experience the abundant life Christ intends for us - one filled with joy, peace and purpose. Instead of simply surviving my own painful life experiences, I’ve experienced triumph as I’ve trusted Jesus through very dark times. It is my greatest privilege and joy to share the truths I’ve learned with others.

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Intake Form

Jan Stanbaugh

Grief Counselor

Intake Form Date

Name

Mobile Phone Number

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Address

Date of Birth

Gender

Male
Female

Spouse's Name

Spouses Age

Years Married

Names and Ages of Children/and or Step Children

Explain

Who referred you to Destiny Biblical Counseling or how did you hear about us?

Religious Background

Religious Affiliation:

Are you Saved and When?

Have you been Baptized and When?

Daily Relationship with God?

Level of Activity

Active
Inactive

Do you attend a local church?

If yes, name of church

How long have you attended your present church?

How significant is your religion to your everyday life?

Occupational Information

Occupation

Employer

How Long?

What concerns have led you to pursue counseling?

When did this begin to be a problem for you?

Please rate the severity of your present concerns.

Mild
Moderate
Severe

What do you hope to gain from counseling.

If other people are involved in your present problem, who are they and how could they help improve the situation?

Medical/Health Information

Are there chemical substance abuse issues in your family?

If yes, who?

If clean/sober, for what length of time?

Have you ever been hospitalized for mental illness or substance abuse?

If yes, for what specific reason and where?

Have you ever participated in counseling before?

If so, when and why?

Name of Therapist

Any other information that you feel is important to share that is not covered?

Terms and Conditions

The Counselor is not providing legal, tax, medical, or other technical or professional advice.

The session content will be held confidential; however, limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the Biblical Counseling Minister has a reasonable suspicion that a client or other named victim is the perpetrator, observer of or the actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

4. Suspicions of elder abuse (60 and older) as in the case stated above (#3).

5. Suspected neglect of the parties named in items #3 and # 4.

6. Your Destiny Biblical Counselor (DBC), reserves the right to discuss your case with other DBC team members in order to come up with the best solution and strategies that will have the greatest impact of success for your specific situation. Your information and case is still strictly confidential outside of the DBC team.

I agree to hold Destiny Christian Church and its team members free from any and all liability, loss or damage of any kind that may arise as a result of assistance which I have received or from my involvement with the Destiny Biblical Counseling Team.

I have read and agree to the terms above.

Suggested Donation Amount is $50.00

Add 3% to my donation to cover credit card fees.

Total

$0.00