Portal — Liberty Christian Fellowship
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Pastoral Care

Please fill out this form as completely as possible.  Thank you!

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
Gender:
Date of Birth:
Primary Phone Number:
May we leave a message here?:
Email Address:
Emergency Contact:
Emergency Contact Phone Number:
Relationship:
May we leave a message with this person?:
Marriage and Family Information: (Please complete if you are currently engaged or dating)
With whom do you currently live?  Please select all that apply?
Name of Spouse:
Spouse's age:
Is your spouse willing to come in for counseling?:
Spiritual/Religious Background
Church Name:
Number of years at church:
Pastor's Name:
How many times per month do you attend church?:
Counseling History
Have you had counseling before?:
Have you seen a psychiatrist before?:
Please describe the current problem, as you understand it:
What have you done about it (most effective and least effective)?:
What are your expectations in coming here?:
What, if any are your concerns about coming to counseling?:
What do you believe you will have to change to see the progress you desire?:
Is there any other information we should know?:
I declare this information is accurate and complete
Signature:
*Today's Date: