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Intake Tool
Form 1 of 4

For your convenience, this section of the ClientCenter is provided so you can complete your required intake paperwork using a computer of other device.

 

NOTICE: Baymeadows Center staff are not permitted to see clients until this paperwork is received, so we ask that you complete and submit this electronic packet 48 hours prior to your first appointment.

Instructions

  1. This entire packet must be completed by, or for, each individule participating in any service provided by BCHH.

  2. If this form is being filled out by an adult for a minor child or a dependent adult under the guardianship of the one filling out the form, the child or dependent adult's name and address are to be used in Section A and your information must be provided in Section B.

  3. If you are simply assisting a person who cannot complete the form on their own, your information must be provided in Section B.

  4. Information provided in this and other forms may be used to determine your eligibility for rate reduction using our sliding-scale rate chart and to determine your rate.

Baymeadows Center for Hope & Healing, Inc. (BCHH)

General Counseling/Coaching Intake Packet

FORM 1 - Demographics

CLIENT DETAILS:

I am completing this intake packet for:

Section A

Client Information
Can leave voicemail
Can send SMS text mesages
Can send SMS text reminders

Section B

Information of the Person Filling Out this Form

Section C

Emergency Contact Information

Used only in the case of a health emergency.

Section D

Referral Information
OR

Section E

Household Income

Used, in part, to determine your Sliding-Scale per session rate. Rate chart can be found at: https://www.baymeadowscenter.org/rates

 

Family Health 360 is a Christian Counseling ministry of Baymeadows Center for Hope & Healing, Inc. It is dedicated to the emotional and spiritual health of every member of your family. Our mission is to help anyone, regardless of their ability to pay, find hope and identify a path to healing through Christ-centered counseling and coaching. Please include all sources of household income when providing the amount of your total household bring-home pay (net).

I testify that the information provided herein is honest and accurate to the best of my recollection.

After you click Submit, you will be taken to the next required intake form.

ADDRESS

1756 University Blvd. S,

Jacksonville, FL 32216

Tel: 904-445-8410

FrontOffice@BaymeadowsCenter.org

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HOURS

BY APPOINTMENT ONLY

Monday - Friday 10:am – 4:30pm

Saturday - By Appointment

 Sunday: Closed

No Walk-in Access

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© 2023 Baymeadows Center for Hope & Healing, Inc., Jacksonville FL 32217

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