Relationship Health Screener Intake Form

Relationship Health Screener Intake Form
As part of the application process for ordination candidacy, spouses are required to attend a shorter assessment at themindspace that looks specifically at marriage health and spousal wellbeing. This is in recognition of the unique impacts of ministry upon ministry spouses and the need to meet with the spouse in addition to the candidate to validly screen for relationship health or wellbeing concerns. Please complete the form below and someone will be in contact shortly to arrange a time for the assessment.
Name:
Date of Birth:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Email
example@example.com
Phone:
Preferred Title

Other
Name Of Spouse
Do you have Children?
Which Denomination or Agency is this report for?

Other
Pre-Interview Agreement
By signing this document I understand the following:

1. themindspace Psychology and Education will retain a copy of the interview data, test results, and final report as per the confidentiality requirements prescribed by the Australian Psychological Society.

2. Raw test data or the test interpretive reports will only be released to a qualified psychologist with experience at test interpretation when written consent is obtained by the applicant.

3. Copies of the final psychological report will only be released to the referring organisation with written consent from the applicant.
First Name* Last Name* Signature* Date*
Upon submission of this form then a number of links for online tests will be forwarded to your provided email. These will need to be completed prior to attending your assessment interview.
Preference for Zoom Appointment (Please allow 90 minutes for this process)
Should be Empty:

Relationship Health Screener Intake Form

Pre-Interview Agreement