Skip to main content
#
Christian Counseling Centers of Indiana, Inc.
  
Staff
How to Reach Us
Forms and Letters
Receive Informational Updates
RESEARCH
NEW COUPLES/CLIENTS
Welcome Page
Personal Questionnaires
PERSONALITY CHARACTERISTICS
ADDICTIONS
Personal Links
PERSONAL  ARTICLES
ANGER
DEPRESSION
OBSESSIVE/COMPULSIVE
ANXIETY
STRESS
PTSD
BIPOLAR
MEMORY
SELF-ESTEEM
EMOTIONS
SCHIZOPHRENIA
BORDERLINE PERSONALITY
BRAIN
SLEEP
PHOBIAS
ALZHEIMER'S DISEASE
Personal & Addiction Counseling
RELATIONAL QUESTIONNAIRES
Relational Links
RELATIONAL  ARTICLES
EXPECTATIONS
AFFAIRS
COMMUNICATION
SEX
CONFLICT
MARRIAGE
SEPARATION
DIVORCE
RESPECT
TRUST
COMMITMENT
FORGIVENESS
EMOTIONS (JEALOUSY)
SPIRITUALITY
FINANCES
TIME TOGETHER
FAMILY OF ORIGIN/LEAVING HOME
PRE-MARITAL
INTIMACY
BONDING
ONLINE DATING
ABUSE
Relational & Marriage Counseling
PARENTAL QUESTIONNAIRES
PARENTAL LINKS
PARENTAL  ARTICLES
PRINCIPLES AND PRACTICES
ABUSE
ADOPTION
ADD/ADHD
DRUG ABUSE
ANXIETY AND DEPRESSION
DEVELOPMENT AND DISORDERS
SEX AND VIOLENCE
ADULT CHILDREN
BULLYING
Blended Families
DISICPLINE
ADOLESCENCE
GRANDPARENTING
SINGLE PARENTING
GROUP HOMES
Parental & Family Counseling
Just For Pastors
COMMUNAL LINKS
COMMUNAL ARTICLES
AREA GROUPS
FINDING A CHRISTIAN COUNSELOR
AGING
Life Coaching
MENTAL ILLNESS
PREVENTION
SUICIDE
TERRORISM
WORK
CHRONIC PAIN/ILLNESS
DISABILITY
PERSONALITY DISORDERS
MEDICATION
PSYCHOLOGICAL CONDITIONS RELATED TO DISEASE & ILLNESS
COLLEGE
THERAPY HELPS
MENTAL HEALTH APPS
Communal & Pastoral Issues
Meditations
SCRIPTURE
CHURCHES
SPIRITUAL LINKS
SPIRITUAL ARTICLES
DEATH AND DYING
GRIEF
Spiritual, Biblical & Christian Counseling Resources
CAREERS FOR COUNSELORS
COUNSELOR'S CORNER
View My Profile on Christian Counselor Directory
 Permission for Release of Information 

I agree to allow the release and exchange of information about me including written reports, progress notes, and telephone calls, between my therapist at Christian Counseling Centers of Indiana and the person or agency listed below.  Please consider this information confidential and share it with only those individuals designated below.

I realize and accept the responsibility for the release of this information and its potential to harm or hinder my treatment or myself in someway.  I understand that this agreement will be in effect until a period of 90 days following the end of my services with Christian Counseling Centers of Indiana.  I also understand that this agreement may be ended at any time by my written notice.

I have requested CCCOI obtain the following information for purposes described below:
*
*
*
*
*
*
*
*
*
*
*
* indicates a required field
Please fill this field.

By submitting this document, you are signing the document electronically.

You agree your electronic signature is the legal equivalent of your manual or handwritten signature on the document. By returning the completed document using any device, means or action, you consent to the legally binding terms and conditions of the document. You further agree that your signature on the document is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature. You are also confirming that you are the patient or guardian of the patient (if the patient is under age 18) authorized to enter into the agreement as described by the document. 

Site Mailing List 

Christian Counseling Centers of Indiana
Two Locations:
Avalon Christian Counseling Center - Fort Wayne, Indiana
Auburn Christian Counseling Center - Auburn, Indiana