Safe Room — Confidential High-Sensitivity & Trauma Care Sanctuary

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Core Intake Forms

Convert / Decision Card One on One Safe Room

THE SAFE ROOMForm 1 of 6

1. Client Intake & Booking

Demographics, concerns, consent & office assignment

Progress17% Completed

Form SR-01: Welcome to the Safe Room

This is a private space to talk with a trained counsellor about anything on your mind. What you share here is treated with care and kept confidential, within the limits explained in Section E.

Section A • About You

Full Name (or the name you'd like us to use) *

Age *

Sex *

State / City *

Phone / WhatsApp *

Email (Optional)

Parish / Zone / Church (Optional)

Section B • What Would You Like to Talk About?

Tick the area that fits best. It's okay to tick more than one:

In a few words, what's on your mind?

How much is this affecting your daily life right now?

Have you spoken to a counsellor about this before?

Custom Sanctuary Assessment Questions

Please respond to these questions to assist our ministry team in preparing your session.

What specific trigger or crisis brought you to the Safe Room today?

Helps our ministry team prepare the right support before your session.

How long have you been dealing with this burden or trauma?

How is this situation affecting your sleep, appetite, or peace of mind?

Are you currently feeling physically safe in your convention accommodation / home?

Have you received professional counseling or medical attention for this previously?

Would you like ministry of deliverance and targeted pastoral prayer during this session?

Section C • Your Safety Check

Right now, do you feel unsafe, or have you had thoughts of harming yourself or someone else?

If you ticked Yes, please tell the desk officer now. You will be seen first, and you won't be in trouble.

Section D • Your Session Preferences

Preferred Time Slot / Duration

Preferred Counsellor

Would you like prayer to be part of your session?

How may we follow up with you after the convention? *

Section E • Consent & Confidentiality

Please read before you sign:

Voluntary. Coming to the Safe Room is your choice. You can stop the session at any time.
Time. Sessions last up to 30 minutes. If you need more time, we will book a follow-up.
Confidentiality. What you share stays between you and the counselling team. We will only share information if there is a serious risk to your life or someone else's, if a child or vulnerable person is being harmed, or if the law requires it. Where possible, we will tell you first.
Referral. Our counsellors are trained volunteers. Where you need specialist help (medical, psychological, legal or financial), we may suggest a referral, but only with your consent.
Your information. Your details are stored securely, used only for your care and follow-up, and handled in line with the Nigeria Data Protection Act 2023. You may ask to see or delete your information.

I have read and understood the above and I agree to receive counselling. *

Client Signature (Type Full Name) *

Date *

Section F • Parent / Guardian / Youth Leader (For Clients Under 18)

Client is Under 18

Clients under 18 are seen with the knowledge of a parent, guardian or designated youth leader, in line with our safeguarding policy.

FOR OFFICE USE ONLYDesk Officer & Intake Triage

Client Code

Time Arrived

Desk Officer

Group Assigned

Counsellor Assigned

Triage Priority: