Pastoral Care Intake Form

Pastoral Care Intake Form

To help us best care for you, please complete the form below.
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
Date
Marital Status:*
Name of significant other:*

First NameLast Name
If separated, divorced, or widowed, please share relevant dates and details:*
Are you a student?*

YesNo
If yes, what school do you attend and what are you studying?*
Are you currently employed?*

YesNoStay at Home ParentStudent
If yes, where are you employed and what is your role there?*
Do you have any children?*

YesNo
If yes, do they live with you?*

YesNo
If no, please explain:*
(Include names and ages of your children)

Please list any members of your household (including self):*

Do you attend Renaissance Church?*

YesNo
If yes, please select which best describes you:*

Member of RenaissanceMember in processRegular attenderOther
If no, are you part of another local church in Pittsburgh?*

YesNo
If yes, which one?*
Are you currently attending a Community Group?*

YesNo
If yes, which Community Group?*
Have you shared the reason you're seeking care with any members of your Community Group?*

YesNoN/A
What is the reason you're seeking care?*

Life StruggleCrisis SituationMarriageFamilyOther
Briefly explain why you're seeking care and when this became a concern for you:*
In addition, briefly explain how this has been affecting you personally: *
Have you received care for this concern before?*

YesNo
If yes, what did this look like?*
What outcomes are you hoping for through the process of care? *
Please select ALL availability that could work for you to meet:*

WeekdaysWeeknightsSunday afternoonsSunday eveningsI can be flexibleOther
Do you give the Elders of Renaissance Church permission to share this information with any appropriate parties to aid in holistic care?*

YesNo
Should be Empty: