Application for Family Counseling
Virginia Institute of Pastoral Care
Denomination: United Methodist
Date of application
-
Month
-
Day
Year
Date
Your Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What is your official status in your denomination?
*
Please Select
Affiliate Member
Associate Member
Bishop
Certified Candidate
Deaconess
Diaconal Minister
Retired Diaconal Minister
Deacon In Full Connection
Elder In Full Connection
Full Time Local Pastor
Certified Lay Minister
Assoc Other Conference
Deacon Member Of Other Conference Or Methodist Denomination
Elder Member Of Other Conference Or Methodist Denomination
Other Non-Methodist Denomination
Provisional Mbr Serving Other Conference
Retired Member Other Conference
Provisional Deacon
Provisional Elder
Part Time Local Pastor
Retired Assoc Member (AM)
Retired Deacon In Full Connection
Retired Elder
Retired Local Pastor (LP)
Retired Provisional Member (PM)
Supplied/Hired/Assigned
Honorable Location
Administrative Location
MOD-Minister, Other Denomin, Serving Ecumen. Par
Probationary Member, 1992 Disicpline
Retired Affiliate Member
Retired Bishop
Minute Question 20
Retired Honorable Location
Retired, Other Methodist
Retired Local Pastor Other Conference
Retired Deaconess
Home Missioner
Retired, Other Denomination
Student Local Pastor
Full Member (Type Unknown)
Other Local Pastor (Type Unknown)
Virginia Temporary
Status listed in VAUMC Clergy Directory.
Full-time or Part-time?
*
Full-time
Part-time
Place of Employment
*
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Marital Status
*
Please Select
Single
Married
Widowed
Separated
Divorced
Age
*
Place of Birth
*
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Annual Gross Family Income
*
Family Group: List the members of your family.
*
Name
Address
Relationship
Age
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Which of the children listed are full-time students (if applicable)?
Referred by (if applicable):
Health Insurance Program
*
Family Physician
*
Prior Counseling Contacts (if applicable)
Dates
Therapist/Agency
Person for Contact
Contact 1
Contact 2
Reason for Seeking Counseling: Please share why you are seeking counseling and what services you are interested in receiving.
*
Acknowledgement of Funds Available: Please sign below to acknowledge that up to $50 is available to you for each visit (26 visit max). You are responsible for paying any remaining balance.
*
Thank you for submitting this application.
Upon hitting the submit button your application will go to the VIPCare staff. They will reach out to you to schedule an appointment.
Submit
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