Great Hebrew Awakening

Welcome to the Great Awakening International Interdisciplinary Team.

YOU ARE NOT ALONE!

We're Here to Help Support you and our community. Get Help to Overcome Life's Barriers by setting up up a meeting to talk to Great Awakening's Interdisciplinary Team

***If you are suicidal or feel like harming yourself please contact 911 immediately. Coming Soon is our 1-800 number for prayer!

INTERDISCIPLINARY TEAM INTAKE FORM

Please take your time in providing the following information. The questions are designed to help us begin to understand you so that our time together can be as productive as possible. All information provided is confidential.

Basic Information

First Name*

Last Name*

City*

State*

Country*

Email Address*

Telephone Number*

Best Time to Call*

Gender*

Age Range*

Do you attend a Church or Assembly?*

Are you affiliated with a GA Assembly?*

Which Assembly are you affiliated with?*

Please check all boxes that best describes your issue(s)? Mental Nutrition and Fitness Financial Family/relationship Issues Medical Care System Advocacy

Please provide a brief description of your issue:

How did you hear about the Interdisciplinary Team?*

Enter What You See

Confidentiality

Policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. It is the policy of the Great Awakening’s Interdisciplinary Team to protect the privacy of every person to the maximum extent possible. Generally, information about you or ministry/services furnished to you will not be released without your prior written consent. There are, however, some circumstances which require the disclosure of information without your consent, such as when:

mandated by state or federal law due to suspicion or knowledge of child abuse and/or neglect or elder abuse and/or neglect,
there is an imminent risk or serious threat of physical harm to self or to others, and
specifically ordered by a court of law.

In accordance with the quality assurance standards set by the Interdisciplinary Team parent entity, The Great Awakening International, your file may be reviewed to ensure record keeping compliance. Also, your coach may discuss your treatment with other consultation groups within the Interdisciplinary Team to ensure the provision of quality care. All Team Members and Groups are obligated to follow laws of confidentiality.

Thank You For Filling Out the Intake Form!

Your intake form has been completed, and you should expect a call from one of our wellness coaches and/or an email to the email address you provided on the questionnaire form.

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