PASTORAL CARE | All Nations Worship Assembly

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PASTORAL CARE

PASTORAL COUNSELING REQUEST FORM

please fill lout the form below and we will respond as soon as we can.

Phone

Name *

Address

Phone Number *

Email Address *

Emergency Contact Name

To notify in case of emergency

Emergency Contact Number *

Emergency Contact Relationship

Birthdate *

Age *

Gender *

Male

Female

Marital Status *

Occupation *

Years Married

If applicable

Years separated, divorced or widowed

If applicable

What church do you currently attend? *

Are you a member at this church? *

How long have you been a member? *

Describe your spiritual life currently? *

Are you currently involved in, or anticipate being involved in any litigation or legal action? If yes, please explain, *

Has counseling been recommended or ordered for you by an attorney, law agency, court, probation, or parole system? If so, please explain *

Are you currently receiving or have you ever received any type of counseling, psychotherapy, psychiatric care or addiction recovery help? If yes, please indicate by noting from whom, when, for what reason and with what results? *

Have you ever attempted suicide? *

Have You Ever Been Hospitalized? *

This includes mental, emotional or an addiction issue? If so, list when, where and why.

Please list your current concerns *

Please describe the reasons for seeking counseling *

Alcohol use/ alcohol abuse

Anger/Frustration

Anxiety

Confusion

Conflicts with co-workers

Depression

Difficulty making decisions

Distance from God

Employment problems

Explosive anger

Family / Marital violence

Family tension

Fearfulness

Financial problems

Hopelessness

Loneliness

Intrusive thoughts

Guilt over the past

Marital difficulties

Parenting struggles

Past Abuse: Physical/Sexual

Past abuse: Emotional/Neglect

Pornography use

Prolonged sadness

Sexual concerns

Social/Relational stress

Spiritual concerns/spiritual confusion

Withdrawing from others

Other (specify below)

(Other)

Please state what you have done so far to solve the problems you mentioned above *

On the scale below please estimate the severity of your problems *

Please state your goals for counseling (how you hope to benefit from counseling) *

Please list any recent loss / crisis: (Family, Relationships, Health, Financial/Job, Other). Please explain.

Is there anything else important for the placement coordinator or your counselor to know about, and that you have not written about on this form? If so, please explain here:

I declare that this information is accurate and complete by signing my name below. *

Today's Date

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