Intake Form

"*" indicates required fields

When we receive your application, one of the Motherless Daughters Facilitators will be in touch with you. Thank you for your interest in this program. It will be an amazing time of healing for you!

Instructions:

Respond to the questions and fill in the boxes
Submit your application

Program Name*

Program Date(s)*

Program Location

Name*

First Middle Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone*

Primary telephone number to reach you*

Email*

Emergency Contact Name*

Emergency Contact Number*

Where did you hear about the ministry?*

Use the fillable blocks to begin telling us your story:

Age at loss*

Cause of mother loss*

Current age*

How many years ago?*

How loss is affecting your life?*

Have you sought any other help or participated in any other groups?*

Have you ever seen a professional counselor?*

Yes

YES:

1. If CURRENTLY:

How does this course fit into your plan of care with your counselor?

Have you talked with your counselor about participating in this program?

Waiver: Submit waiver. Then complete your personal story.

2. If PREVIOUSLY:

Why?

What was the outcome of your counseling?

If NO:

Submit your intake story. Complete Your Story of personal loss:*

Counselor Waiver

I understand that the Motherless Daughters Ministry, Inc. is a Christian based program consisting of specially trained volunteers who serve as facilitators and leaders of the ministry. The ministry is not a counseling service and the leaders are not trained counselors or therapists.

It is important that you work in tandem with your therapist or counselor so the program you are attending will be an adjunct to your treatment plan. Hence it is important that we have your permission to do the following.

I give permission for the Motherless Daughters Ministry, Inc. Facilitators and/or Executive Director to provide information to my mental health counselor or therapist upon request as it relates to the Motherless Daughters Ministry, Inc. program content and my participation.

Counselor Name

Address

Phone

Consent

This consent is valid for the time I am in the Motherless Daughters course as specified below:

Course Name*

Course Dates*

I may revoke this consent at any time by notifying the Motherless Daughters’ Facilitators in writing. If this consent is revoked during the time I am participating in a Motherless Daughters program, I can not continue participation in the course.

Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed and/or initialed, and that any electronic signatures and/or initials appearing on this Agreement or such other documents are the same as handwritten signatures and/or initials for the purposes of validity, enforceability, and admissibility.

Signature*

Witness*

This field is for validation purposes and should be left unchanged.