top of page
motivation-event.jpg

Intake Form

Please Complete the Counseling Intake Form:

Counseling Intake Form

Personal Information

Birthday
Month
Day
Year
Multi-line address
Member
Yes
No
Marital Status
Married
Single
Widowed
Divorced
Separated
Do you have children?
Yes
No

If yes, please list them below and designate stepchildren as (Step).

Parent and Sibling information:

Medical Information

Are you under the care of a physician, psychologist or psychiatrist?
Yes
No
Please Rate your Health
Excellent
Good
Average
Poor
Have you had any counseling before?
Yes
No
Are you on medication?
Yes
No

If yes, please list your medication?

Have you used drugs for other than medical purposes?
Yes
No

If yes, please explain:

Have you struggled with any kind of addiction?
Yes
No
Uncertain

If yes, please explain:

Have you ever been sexually, physically, spiritually or emotionally abused?
Yes
No

If yes, please explain:

Have you ever seriously considered or attempted suicide?
Yes
No

If yes, please explain:

Have you ever been arrested?
Yes
No

If yes, please explain:

Emergency Information

In case of emergency, who should we notify?

Multi-line address

What Brings You To Counseling?

If you were to die today, would you spend eternity in Heaven?
Yes
No
Uncertain

If yes, please explain:

Please complete the following statements:

In the past 12 months I have experienced…

Multi choice

If there is something other than what is above please explain below:

Consent to Counsel

A. MINISTRY COUNSELING MODEL

Healing Glory Ministries, Inc. is a non-profit, non-denominational, faith-based, and Christ-centered caregiving/counseling organization. Our scheduling hours are flexible, and we make every effort to accommodate your scheduling needs. For now, all of our caregiving services are virtual.


Healing Glory Ministries, Inc. employs the Formational Care counseling model which utilizes an integration of spiritual/biblical and well-tested psychotherapeutic principles to help care receivers/counselees, either individually or in groups, undertake a deep healing journey with the Lord Jesus Christ. In our caregiving process, the Holy Spirit, not the caregiver, is the agent of change – provided the individual/s cooperate/s with Him. The care receivers are engaged in a structured week to week teachings that allow them to reflect upon the very painful and wounded parts of their story, make space for Jesus to meet them in these wounded places, and bring wholeness and healing. Our goal is to convey the way of freedom from mental and emotional symptoms, spiritual, familial and marital conflicts, as well as other difficulties, by utilizing the Formational Care model. The focus of our counseling is not on behavioral change but on the spiritual transformation of the individual.


Our unique model includes but is not limited to establishing goals for counseling, the gathering of personal history in order to identify false beliefs that are currently affecting the individual’s view of God, self and others, participant’s personality assessment using the Wired That Way assessment tool, the provision of truths and tools designed to introduce the solution to the problem at hand—understanding one’s identity in Christ, and a safe place to experience God’s presence in the healing process. As each participant journeys through this counseling model, he/she will become aware of Christ’s sufficiency for meeting all of his/her needs by learning to relinquish dependency on his/her own ways. This allows Christ to live in and through the individual, and this empowers people to address the influencing factors that are causing conflict and frustrations within relationships. Some of the matters that will be addressed are personal brokenness, grief, surrender and forgiveness. Our role in this healing journey is to disciple the participant in abiding in Christ and in the renewing of the mind with His truth, as he/she walks through all of the steps that lead to freedom. For married couples, our unique model incorporates the Prepare/Enrich program to help participants evaluate their relationships on the basis of a number of parameters, including personality strengths and weaknesses, communication, conflict resolution, personal stress profile, relationship satisfaction, and Couple and Family maps. Following these evaluations, participants are given tools to help resolve their current struggles and enrich their relationship.

B. MINISTRY COUNSELING CREDENTIALS

Healing Glory Ministries, Inc. is a very young outfit and is currently being run by its founder, Dr. Otu Onofiok. We hope to staff the ministry very soon. Dr. Onofiok holds a Master’s degree in Christian Counseling and has been engaged in discipleship counseling for over eighteen years. Within that period, he has acquired more training hours in psychotherapeutic techniques, including Personality Assessments Tools and various coaching techniques giving him a more integrative approach to caregiving. Dr. Onofiok has helped several individuals and couples find Christ-centered solution to their issues and led many in their healing journey with Jesus Christ to the desired end of wholeness. His greatest credential is that he has personally walked through and Consent to Counsel 6 experienced a personal transformation, with the counseling model employed here. Dr. Onofiok is certified through The Board of Examiners for Georgia Christian Counselors and Therapist, and/or ordained ministers.

C. FINANCIAL POLICY

Individuals receiving help are encouraged to support this ministry with a donation of $100.00 per one-hour session. Since Healing Glory Ministries depend upon such monies to meet its needs, prayerfully consider the opportunity/responsibility to give $100.00 per one-hour session. It is important that you have an investment in your healing, therefore we will be glad to help you discern an amount if you are currently experiencing financial distress. You will be given an opportunity to make your donation at the end of each session.


Your donation may not be tax deductible since you are receiving a service.

D. APPOINTMENTS, CANCELLATIONS, AND CLIENT RESPONSIBILITES

If you must reschedule your appointment, we ask that you please notify our office 24 hours in advance. Should no one be available to speak with you personally, please call back to reschedule your appointment. If you do not call and do not show up for a scheduled appointment, you will still be asked to pay a $30.00 administration fee for that appointment. Those who participate in counseling are required to:


  • Attend all sessions

  • Be on time

  • Have a heart’s desire for knowing Christ and for growing to maturity in Him.

  • Understand that behavioral changes such as communication skills, problem-solving techniques, and anger management strategies will not be considered the solution to your problems. However, they will be taught throughout your sessions. Personal transformation in Christ is the only answer and hope for relational and personal issues.

  • Do not expect your personal healing and peace to depend on your circumstances, spouse or another person changing. The only way to find fulfillment and freedom from emotional pain is in understanding God’s grace, knowing your identity in Christ, and in pursing an intimate relationship with Him.

  • Complete weekly homework. This may involve an hour + per week. Homework may include reading, writing, listening, doing relational exercises, or all of the above. Commit to homework as each session builds upon the previous session and upon the homework. Counseling is not effective if you are not invested in your healing.

  • Agree to refrain from discussing your problematic relationships with anyone else outside of your counseling sessions. Allow God the opportunity to work!

  • Do not participate in counseling because a spouse or another person is expecting it but because you have a desire for personal change through knowing Christ. Those who decide to come in for couples’ counseling must understand that one spouse is not to participate as a result of an ultimatum given by the other spouse. Both must agree with our stated perspective.

  • Realize that the purpose of counseling will not be to change another person with whom you are in relationship.

E. CONFIDENTIALITY COMMITMENT

All information disclosed to your counselor will be kept in strict confidence. Intakes, notes and personal testimonies taken by, given to, or shared with Healing Glory Ministries will not be transferred to anyone 7 except when the information is used in consultation (refer to Section F. below). However, individuals receiving counseling can expect confidentiality to be modified in the following situations:


  1. When the personal safety of the counselee or another person is at risk.

  2. When any form of child abuse (physical or sexual) or child neglect is disclosed or suspected by your counselor.

F. CONSULTATION CONSENT

I do hereby give my consent for my counselor to consult with others (e.g., pastors) that the ministry may deem appropriate to consult with in the following circumstances: in order to assist in the assessment of my counseling concerns, for the purpose of providing the best possible help, in obtaining recommendations, to formulate treatment strategies, or when considering an appropriate referral.

G. OUR AGREEMENT TO ENTER INTO A THERAPEUTIC RELATIONSHIP

I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask your counselor.


Please sign and date your name below indicating that you have read and understand the contents of this form, you agree to the policies of your relationship with your counselor, and are authorizing your counselor to begin a healing journey with you.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
home3-12.jpg

Join Us

We’d love to work with you in your journey to healing and wholeness.

Logo-Healing-Glory-Ministries_edited.png
Contact

PO Box : 519 Dacula, GA 30019

©2025 Healing Glory Ministries- All Rights Reserved

bottom of page