COUNSELEE INFORMATION FORM

 

Please print form and give to Senior Pastor.

 

Name:_________________________________________________________     Age: _______________________

Marital Status:      Married / Single    (Circle one)                        How Long:___________________________

Spouse’s Name (if applicable): __________________________________________________________________

Address:_______________________________________________________________________________________

City: _____________________________________________    State: ______________     Zip:_________________

Home Phone: ______________________________________    Work/Cell Phone:___________________________

Children & their Ages: ____________________________________________________________________________

Member of Pinelands:     Yes / No

1.   How did you hear about this ministry? ____________________________________________________________

 _______________________________________________________________________________________________

 

2.   For what are you seeking help? __________________________________________________________________

 _______________________________________________________________________________________________

 

3.   When did you first notice this concern? ____________________________________________________________

 ________________________________________________________________________________________________

 

4.   Have you had counseling before?    Yes / No

 

5.   If so, for what and where? _______________________________________________________________________

 _______________________________________________________________________________________________

 

6.   What were the results of your counseling? _________________________________________________________

 ________________________________________________________________________________________________

  

If you are seeking professional counseling, please call the church office for more information (609) 812-0073.