Marital Pastoral Counsel Request Form

Marital Counseling Request Form

for Spiritual Pastoral Counsel
* Those requesting Marital Counsel MUST COMPLETE THIS FORM TOGETHER! Please do not try to complete this form wityout your spouse's consent. Both of you must be willing to come and meet with the pastors to receive this counsel.
Today's Date

Month Day Year
Name *

First Name Last Name
Spouse's Name *
First Name
His Age
Approximate is fine
Her Age
approximate is fine
E-mail *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Texting Ok?

Yes No
His Occupation
Her Occupation
Personal Information
Marital Status
Do you have any children

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

His Health Information
Rate your Health:
Please list any other pertinent health information, drug use, chronic conditions present problems, or weight changes:
His 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 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.
His Name *

First Name Last Name
Her Name *

First Name Last Name
Should be Empty:

Marital Counseling Request Form