Individual Pastoral Counseling Request Form

Individual Counseling Request Form

for Spiritual Pastoral Counsel
What type of Spiritual Counsel are you looking for?

Marriage Individual*
For SOZO MINISTRY, please go back to the website and choose "Sozo Request Form". This form is for individual pastoral counseling only.

* Those requesting Individual Counsel MUST COMPLETE THIS FORM THEMSELVES! Please do not try to complete this form for your spouse.
Name *

First Name Last Name
Today's Date

Month Day Year
E-mail *
Age
Sex

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Texting Ok?

Yes No
Occupation
Personal Information
Marital Status
Spouse's Name (if applicable)
Do you have any children

Yes No
How Many
Were you raised by anyone other than your own parents? If so, please explain:

Health Information
Rate your Health:
Please list any other pertinent health information, drug use, chronic conditions present problems, or weight changes:
Previous / Current Care Information
Are you currently taking any medication for mood, depression, anxiety, etc? If so, please list them.
Are you currently under the care of a counselor or therapist?

Yes No
If yes, Name:
Have you met with a Pastor or Elder of Vanguard Church before?

Yes No
Please list any Pastors, or Counselors you've seen with approximate dates:
What was the outcome?

Reason for Counsel
Did someone recommend Spiritual/Marital Counseling at Vanguard? If so who?
Briefly answer the following questions:
1. Please describe your need or the reason you would like counsel?
2. What have you done to try and resolve it?
3. What are your expectations in coming here?
4. Is there any other information we should know?
5. Have you met before with any other Pastors or Elders here at Vanguard regarding the same reason? If so, with whom and when:
By typing your name below (as your electronic signature) you agree with this statement:

I understand that the counseling given at Vanguard Church is Spiritual Counseling, based on biblical principles and prayer. Typically, all forms and sessions will remain confidential. In rare cases that have the potential to impact the church body, I acknowledge the biblical model of church oversight which involves all pastors and elders in the process. In the event that I cannot make my appointment, I will call the Church Office to cancel and/or reschedule with 24 hours notice.

I agree to do my part, preparing my heart to hear from the Lord; and searching the scriptures regarding this issue. I will also spend time in prayer and ask the Lord what He wants me to work on, and consider fasting in preperation for my pastoral counseling appointment.
Name *

First Name Last Name
Date *

Month Day Year
Should be Empty:

Individual Counseling Request Form