PASTORAL CARE PASTORAL COUNSELING REQUEST FORM please fill lout the form below and we will respond as soon as we can. Company 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 * Single Engaged Married Divorced Separated 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? * Yes No 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? * Yes No 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 * Mildly upsetting Moderately upsetting Very upsetting Extremely upsetting 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