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Children / Adolescent
Admissions Forum

Adolescent New Patient Information Form

To help your clinician understand your concerns, please answer the following questions.

  • MM slash DD slash YYYY
  • What is your primary reason for having the child come to Faithful Love Missionary Christian Counseling Center?
  • Please check any concerns you may have about the child in the boxes below:
  • Please check the box that best represents the Child's/Adolescents race/ethnic background:
  • Are parents divorced or separated?
  • Please tell us about the household/family with whom the child spends the majority of his/her time (or who currently lives with the child/adolescent). List primary household information first, then list other living situations/supportive relationships:
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.g. sibling, step-parent, extended family)
  • Is this child adopted?
  • (e.g.: mother had significant illness, smoked cigarettes, drank, experienced severe bleeding, etc.)
  • (e.g. needed to be revived at birth, failure to thrive, missed significant development milestones)
  • If necessary, the current therapist may ask you to complete a more extensive history of your child's early development.
  • What are a few areas where the child excels?
  • Where does the child attend school?
  • Has your child ever received previous counseling, therapy, or psychiatric treatment?
  • If yes, can you please describe: (When, where, for what purpose, the results, and reason for terminating treatment recovery)
  • Has the child/adolescent ever been the victim of abuse or neglect?
  • Please list any contacts the child has had with the courts (including Friend of the Court)
  • What is the child's present religious affiliation?
  • Does the child/adolescent have any current medical concerns?
  • Please List all current medications and/ or supplements the child's/adolescents is currently taking:
  • Biological Father's Name
  • DO YOU PROVIDE SERVICES TO CLIENTS AT RISK OF SUICIDE ? We also create specialized individual customized programs for sexual abused or physical abused victims. Our Suicide watch services is the only service currently offered to clients and their families at Faithful Love Missionary Christian Counseling Center to support patients with self harming behavioral until a psychiatric hospital environment is found.
  • DO YOU OFFER OTHER SERVICES FOR AT RISK CLIENTS? No, Faithful Love Missionary Christian Counseling Center Christian Counseling services or behavioral intervention are not recommended for clients that are active in self-harm or at risk, we understand the needs of our clients. Our Crisis response services is always available to you or your family member for constant or one on one crisis care. We understand that mental illness and trauma often go hand in hand and offer cognitive behavioral therapy for clients suffering from dual diagnosis and co-occurring conditions simultaneously.
  • Servicing Children, Adolescents and Woman At Faithful Love Missionary, we specialize in mental health and behavioral health coaching and provide expert faith-based therapy to aid personal growth and empowered healing among adolescents and young adults.
  • Book an Appointment Receive, your first session today Get in touch with our Faithful Love team of Expert Christian counselors for expert guidance and helpful advice for any fears, insecurities, or personal crisis by simply filling out the form below! Or Call today. Our amazing young people and women that benefited from our faith-based counseling and behavioral health recovery:
  • I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes regarding the above information.
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  • MM slash DD slash YYYY
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The Mission

All of God Jehovah’s children are perfect.

Our mission is to honor God Jehovah by empowering, serving, and loving all of God’s children as he does; one at a time, with Faithful Love. In the mighty and matchless names of Christ Jesus.

The Christian counselors at Faithful Love are empathetic and non-judgmental. If you are struggling with social anxiety our services will change your life. Faithful Love Missionary will help you get to the underlying issue and all concerns will be addressed through a series of Christian counseling sessions. The Crisis Center hotline support is also extremely helpful too. You'll be glad you chose them!
Call Today!
Faithful Love Missionary Christian counselor helps clients get through the dark time in their life. The coping strategies that are learned helps to manage setbacks. Faithful Love Missionary Christian counselor really help with depression. Quality services and a happier life with the best perspective is what you'll receive here. You'll heal from the inside out.
Call Today !
The Christian counselors at Faithful Love are full of passion, power as they transfer a sound mind with the biblical scripture. You don't have to struggle with harmful patterns of thinking or feel caged in your life. Faithful Love Missionary Christian Counselors will help you get the help you need in each Christian counseling session. You're not alone, tomorrow doesn't have to wait!
Call Today !
Faithful Love Missionary Pastoral Christian Counselor & mental health coach will help you get through the dark time in your life. The coping strategies that you'll learn will help you manage the setbacks. Faithful Love Missionary's Christian Counselor and mental health coach will really help you with depression. Happy is the one who receives these services with maximum restoration!
Call Today!
Book A Session Today
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For more questions get in touch with our Faithful Love Missionary team of expert Christian Counselors. Faithful Love Missionary Christian Counseling Center experts provide guidance with matchless therapy to transform any fears, insecurities, or personal crisis that child, adolescent, youth-adult women, women and family will ever have.

 Faithful Love Missionary Christian Counseling Center Services are designed For Children, Adolescents, Youth- Adult Women, Women And Their Families.

At Faithful Love Missionary Christian Counseling Center, we specialize in mental health and behavioral health recovery provide expert faith-based therapy to aid personal growth and empowerment with the deliverance of healing. Call Today!

Our Focus

Faithful Love Missionary Christian Counseling Center experts provide guidance with matchless therapy to transform any fears, insecurities, or personal crisis that Children, Adolescent, Women, And Their Family will ever have.

For more questions get in touch with our Faithful Love Missionary team of expert Christian Counselors.

Faithful Love Missionary Christian Counseling Center Services are designed For Children, Adolescents, Adults, And Their Families. At Faithful Love Missionary Christian Counseling Center, we specialize in mental health and behavioral health recovery and provide expert faith-based therapy to aid personal growth and empowerment with the deliverance of healing. Call Today!

CHRISTIAN COUNSELING
Intensive Christian Counseling
Biblical Behavioral Health Care
LIFE COACHING SESSIONS
Christian Marriage Counseling
ONLINE SERVICES
Plan Of Care & Cost
The Good News

Enjoy Our Christ-Centered Masterpiece

In the mighty, yes the mighty ,the mighty and matchless name of Christ Jesus. I surrender, it is He. Speak his name and say it out loud
“He Is In Me!”
Christ Jesus IS my lock, my keys and, my rock, “he is in me”greater is he, yes he in me.
If we are faithless, he remains faithful — for he cannot deny himself.
2 Timothy 2:13ESV
But the Lord is faithful. He will establish you and guard you against the evil one.
2 Thessalonians 3:3ESV
If we confess our sins, he is faithful and just to forgive us our sins and to cleanse us from all unrighteousness.
1 John 1:9ESV
God is faithful, by whom you were called into the fellowship of his Son, Jesus Christ our Lord.
1 Corinthians 1:9ESV
Let us hold fast the confession of our hope without wavering, for he who promised is faithful.
Hebrews 10:23ESV
What if some were unfaithful? Does their faithlessness nullify the faithfulness of God?
Romans 3:3ESV
Your steadfast love, O Lord, extends to the heavens, your faithfulness to the clouds.
Psalm 36:5ESV
Moreover, it is required of stewards that they be found trustworthy.
1 Corinthians 4:2ESV
O Lord God of hosts, who is mighty as you are, O Lord, with your faithfulness all around you?
Psalm 89:8ESV
Your faithfulness endures to all generations; you have established the earth, and it stands fast.
Psalm 119:90ESV
And I am sure of this, that he who began a good work in you will bring it to completion at the day of Jesus Christ.
Philippians 1:6ESV
Now faith is the assurance of things hoped for, the conviction of things not seen.
Hebrews 11:1ESV
“One who is faithful in a very little is also faithful in much, and one who is dishonest in a very little is also dishonest in much.
Luke 16:10ESV
Keep your life free from love of money, and be content with what you have, for he has said, “I will never leave you nor forsake you.”
Psalm 89:33ESV
But I will not remove from him my steadfast love or be false to my faithfulness.
Psalm 89:33ESV
For I said, “Steadfast love will be built up forever; in the heavens you will establish your faithfulness.”
Psalm 89:2ESV
Heaven and earth will pass away, but my words will not pass away.
Matthew 24:35ESV
Paul, an apostle of Christ Jesus by the will of God, To the saints who are in Ephesus, and are faithful in Christ Jesus:
Ephesians 1:1ESV
Who was faithful to him who appointed him, just as Moses also was faithful in all God's house.
Hebrews 3:2ESV
I know, O Lord, that your rules are righteous, and that in faithfulness you have afflicted me.
Psalm 119:75ESV

In The Name Of Jesus Christ

Our Christ-Centered Masterpiece

In the mighty yes, the mighty and matchless name of Christ Jesus I surrender, it is He. Speak his name and say it out loud “ He In Me!”
Christ Jesus IS my lock, my rock and, my keys, “he is in me”
If we are faithless, he remains faithful — for he cannot deny himself.
2 Timothy 2:13ESV
But the Lord is faithful. He will establish you and guard you against the evil one.
2 Thessalonians 3:3ESV
If we confess our sins, he is faithful and just to forgive us our sins and to cleanse us from all unrighteousness.
1 John 1:9ESV
God is faithful, by whom you were called into the fellowship of his Son, Jesus Christ our Lord.
1 Corinthians 1:9ESV
Let us hold fast the confession of our hope without wavering, for he who promised is faithful.
Hebrews 10:23ESV
What if some were unfaithful? Does their faithlessness nullify the faithfulness of God?
Romans 3:3ESV
Your steadfast love, O Lord, extends to the heavens, your faithfulness to the clouds.
Psalm 36:5ESV
Moreover, it is required of stewards that they be found trustworthy.
1 Corinthians 4:2ESV
O Lord God of hosts, who is mighty as you are, O Lord, with your faithfulness all around you?
Psalm 89:8ESV
Your faithfulness endures to all generations; you have established the earth, and it stands fast.
Psalm 119:90ESV
And I am sure of this, that he who began a good work in you will bring it to completion at the day of Jesus Christ.
Philippians 1:6ESV
Now faith is the assurance of things hoped for, the conviction of things not seen.
Hebrews 11:1ESV
“One who is faithful in a very little is also faithful in much, and one who is dishonest in a very little is also dishonest in much.
Luke 16:10ESV
Keep your life free from love of money, and be content with what you have, for he has said, “I will never leave you nor forsake you.”
Psalm 89:33ESV
But I will not remove from him my steadfast love or be false to my faithfulness.
Psalm 89:33ESV
For I said, “Steadfast love will be built up forever; in the heavens you will establish your faithfulness.”
Psalm 89:2ESV
Heaven and earth will pass away, but my words will not pass away.
Matthew 24:35ESV
Paul, an apostle of Christ Jesus by the will of God, To the saints who are in Ephesus, and are faithful in Christ Jesus:
Ephesians 1:1ESV
Who was faithful to him who appointed him, just as Moses also was faithful in all God's house.
Hebrews 3:2ESV
I know, O Lord, that your rules are righteous, and that in faithfulness you have afflicted me.
Psalm 119:75ESV

In The Name Of Jesus

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