Counseling Request Form

Counseling Request Form - Individual

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

Marriage Individual Sozo (Inner Healing/Deliverance)
Name *

First Name Last Name
Today's Date

- Month - Day Year
E-mail *
Age
Sex

Male Female

Address

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
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:

Counseling Request Form - Individual