• Ministry Counseling Request Form

    Please fully complete this application to schedule a counseling session. Once you have submitted the form and the release of liability (at the bottom of this application) you will be contacted by an administrator to schedule your session.
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  • These questions are designed to help us assess your needs and potential ministry opportunities. Please answer them truthfully -- it will greatly improve the quality of the ministry you receive at your counseling session.

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  • I acknowledge that Pastor Keith Moore from Bread of Life Community Church has voluntarily agreed to pray for me.

    I understand that this session is not a professional counseling meeting. I understand that he is, to the best of his ability, doing what hecan to help me achieve more freedom in my life.

    I understand that Bread of Life Community Church is a nonprofit Florida Corporation that does not charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the Pastor of this ministry.

    I understand that if I receive ministry from the Bread of Life Community Church, the team is committed to respect the disclosed information. I agree to hold Bread of Life Community Church free from any and all liability, loss or damage of any kind that may arise as a result of assistance which I have received.

    I have read this disclaimer and release of liability and understand and agree with it and have executed it as my free and voluntary act.

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