Counseling Request | eclife.org

First Name

Last Name

Gender

Male Female

DOB

/ /

Age

Address

Email

Phone

Marital Status

Single Married Separated Divorced Widow(er)

Have you ever been separated in the current marriage?

Yes No

Spouse's First Name (If Married)

Have either of you ever filed for divorce?

Yes No

Have you been married before?

Yes No

Please list all children below (Name, Age, Gender, Living with you? Yes or No)

Please describe the reason you are seeking counseling

If married, will your spouse be attending?

Yes No

Have you had counseling before?

Yes No

Are you currently seeing a counselor?

Yes No

Are you presently on medications?

Yes No

Where do you currently attend church?

How did you hear about counseling services offered here?

If Other, please describe

It is our desire to offer appointments that are convenient for you. Please indicate which day and time you would prefer.

Day and time preference

Monday mornings 8-11 am Monday afternoons 1-4pm Tuesday morning 8-11 am Tuesday afternoons 1-4 pm Wednesday mornings 8-11 am Wednesday afternoons 1-4 pm Thursday mornings 8-11 am Thursday afternoons 1-4 pm Sunday mornings 9:00am-11am

I/We affirm the accuracy of the personal information provided herein, have read the information and agree to the conditions set forth. I/We hereby agree to the following conditions:

I/We understand that Emmanuel may have lay people training, and therefore, agree to have a trainee(s) in the counseling session with me (us).
I/We agree to hold the Counselor harmless from any advice, counsel or suggestions rendered during our counseling sessions. I recognize that their role is to assist me/us in hearing and understanding God’s will in the matters discussed. I/We will not, therefore, sue or engage in any type of litigation negatively affecting them.

Having clearly stated the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body. If you have questions about these guidelines, please talk with your counselor. If these guidelines are acceptable to you, please sign and date below.

I have read the above and understand the policies stated above. I consent to abide by them. This form must be completed prior to scheduling an appointment.

Yes

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