812-244-0400 jetdevans@gmail.com

Primary Client Registration Form

Please fill out the form below.

If you would prefer to use a hard copy of the form and send it in by mail, click the button to download a PDF copy.

Primary Client Registration Form


PERSONAL DATA INVENTORY



CURRENT ISSUES


FAMILY HISTORY


MARITAL STATUS


YOUR FAITH JOURNEY


SUBSTANCE USE/ABUSE


YOUR EDUCATION


MILITARY SERVICE


EMPLOYMENT HISTORY


LEGAL HISTORY


DISABILITIES


EMERGENCY CONTACT


OUR FEE SCHEDULE

 

Our sliding scale fee schedule is based on annual family income. Please check the level that applies.

  • Up to $50,00 per year - $55.00 per session
  • Up to $60,000 - $65.00 per session
  • Up to $70,000 - $75.00 per session
  • Up to $80,000 - $85.00 per session
  • Up to $90,000 - $95.00 per session

We do not bill any insurance for our services, but we can provide an insurance coded receipt. Some insurance companies may reimburse for services. Most will not.


Our counselors adhere to biblical principles in all approaches and methods to counseling. We provide counseling services that address but will not necessarily be limited to:

  • Depression / Anxiety

  • Pornography and Other Sexual Addictions

  • Premarital Counseling

  • Planned and Unplanned Career Changes

  • Parenting Skills

  • Anger / Bitterness

  • Childhood Behavioral Issues

  • Family Conflict and Communication Difficulties

  • Physical, Emotional, and Sexual Abuse

  • Substance Abuse

  • Divorce Care

  • Grief and Suffering

  • Lifes Changes Due to Health Issues

  • Crises of Faith

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