Member Help Form
(Each person desiring counseling needs to fill out separate form.)
Select a date
(No Dashes Needed)
Date of Birth
Referred to Counseling by:
Are you receiving care from one of the other pastor's at the present time?
Date of Marriage:
Have you ever been separated from your present spouse?
Have you had any of the following physical problems? (please check all that apply)
Change in Sexual Drive
Unusual Hair Loss
CHanges in Consciousness
High Blood Pressure
How many hours of sleep do you average each night? Have there been any recent changes? Is this sleep restful?
Have you or others noticed any changes in your thinking and memory, or work habits?
State in your own words the nature of the main challenge(s) that brings you for counseling:
When did your problems begin? (please specify a date if possible)
Please describe any significant events occuring at that time.
What have you done to try to resolve your problem(s)?
Is there any other information I should know?