MCC Religious Consultations Intake Form
The information you provide in this form is strictly confidential.   Consults are 20-30 minutes and are not meant to be ongoing counseling.
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Email *
 Your Name *
Who will the religious consult session be for? *
Names of all persons who will be at meeting? * *
Age(s) of youth(s) who will be attending/discussed at session? *
Your Phone Number *
Can we send you communications by email regarding this matter? *
Is it ok to leave a voicemail regarding this matter on the number you provided? *
Describe the issue that you are requesting spiritual counseling for *
How long have you been experiencing this issue for? *
What have you done to deal with this issue? *
How do you hope a religious consult might help?  What are your expectations in coming here?  Please briefly describe what you would like to gain from the religious consult. *
What brings you here for this issue at this time? Did any recent event cause you to schedule the appointment now? *
Is there any other information you think we should know to help you? *
Have you talked with another Imam, Shaykh, teacher, faith leader, chaplain or community leader about this issue? *
If yes, who did you speak with and what was the result of your previous consult or counseling?
Are you, or the person that you are seeking counseling for, currently under the care of a psychologist, psychiatrist, or other mental health professional? *
The MCC religious consult is not a clinical counseling service.  The consultants are not trained as, nor act as, licensed psychologists, psychiatrists, therapists, or any other type of professional mental health care provider.   There will be no attempt to render a psychological evaluation or diagnosis.  If you have significant legal, financial, medical, or other technical questions, you should seek advice from a Khalil Center professional or another mental health agency or professional. *
Required
I/(We) agree to release the MCC East Bay, its Board and employees from any legal liability, claim, or litigation arising from my/our spiritual counseling session. *
Required
Confidentiality is extremely important to us. As legal guardian, you have a right to be involved in the counseling your child receives. We will protect the confidentiality of you and/or your child’s visit(s), but there are limitations to confidentiality that you must be aware of. Consults are based on a trusting relationship between consultant and client.  The consultant will keep information shared by the client confidential, except in certain situations in which an ethical responsibility limits confidentiality. You will be notified under the following circumstances: 1. The child reveals information about hurting himself/herself or anther person.2. The child or another person may be in physical danger.We are required by law to report any incidence of suspected child abuse, neglect, or molestation in order to protect the child involved. *
Required
This RELEASE and Waiver of LIABILITY is made once this form is submitted, between the Consultant and Client; and, if the Client is a minor, the Client's parent or legal guardian.As a precondition to any and all spiritual counseling services to be provided by the counselor, the undersigned, in consideration of the services provided by the counselor, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the counseling relationship/services as a direct or indirect result of any involvement Client may have with the consultant or the counselor’s mosque/community or any other partnering/hosting mosque/community center.Client further understands that it is the specific intent and purpose of this legal document to release and discharge any and all claims and causes of action of any kind or nature, which are directed toward a Consultant, Imam, Shaykh, Ustadh, Murabiy, Mosque or the Muslim Community Center East Bay. This includes causes which are known or unknown, specifically mentioned or implied, or not mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document. The undersigned further specifically waives any claims or right to assert that any cause of action or claim or demand has been, through oversight or error, intentionally or unintentionally omitted from this release. The undersigned also understands that the Consultant is trained is Quran and Hadith and will offer advice from the Deen but is not state licensed and not under the regulatory authority of any governmental agency.  The advice given is based on how to think rationally and clearly from a Islamic perspective only. I HAVE READ AND UNDERSTAND ALL OF THE ABOVE. *
Required
I understand that Sh. Rami Nsour will review my answers and if he feels I/we would benefit from religious consultation, he will email us with a list of dates and times that he can meet with me/us in a 30-minute increments. Once I schedule a time, I promise to honor his time and arrive five minutes prior to the start time and inform him immediately if I need to reschedule. *
Required
I understand that for scheduling appointments, follow ups and possibly gathering further information, I may be contacted by an assistant to Sh. Rami.  This person will be a qualified and trained assistant who will hold all information under strict confidentiality. *
Required
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