Ministry Session Info Request
Please fill out the information as best as you can so we know how to best serve you. Looking forward to connecting with you!
Name
*
First Name
Last Name
Date of Birth
*
Please select a day
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Day
Please select a month
January
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Month
Please select a year
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Year
Gender
Please Select
Male
Female
Not willing to Disclose
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Where/how did you hear about us?
*
What is your main concern/reason for your session request?
*
Have you ever received counseling before?
*
Yes
No
Are you currently receiving counseling from someone else?
*
Yes
No
If yes, from whom?
Are there areas you’ve already received ministry or help? If yes, what areas?
*
Which type of session would you like to make an appointment for?
Please Select
Counseling Session
Prayer Ministry
Something Else
Are you familiar with Jesus Wonderful Counselor prayer ministry?
*
Yes
No
How would you rate your current relationship with Jesus? 1=Poor 2=Needs Improvement 3=Going OK 4=Good 5= Excellent
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Is there anything else you’d like us to know?
OPTIONAL: Would you prayerfully consider donating to help our ministry? This is completely optional, so please do not let this be a hindrance for receiving what the Lord has for you. If you'd like to skip this section, type ZERO ( 0 ) on the USD area then scroll down to “submit”. — Thank you!
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( X )
USD
OPTIONAL Suggested Gift Amount — Adjustable, you can enter any amount you feel led to give. -Thank you!
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
After you click the “Submit” button, you’ll be taken to our calendar where you can pick a day/time to meet.
Looking forward to meeting with you!
May the Lord bless you and keep you, make His face shine upon you and give you peace.
Submit
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