PASTORAL CARE

PASTORAL COUNSELING REQUEST FORM

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

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 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