Couples Discipleship- Request Form
Requirements to receive Couples Discipleship
BOTH individuals must fill out and sign a separate form and submit it before being scheduled for a session. The TK Office Admin will reach out within 3-5 business days after receiving both form to discuss scheduling options.
Disclaimer
Due to limited resources, we prioritize Church Tsidkenu members with scheduling. Non-Tsidkenu members are still eligible to receive a Couples discipleship session but might be scheduled out farther in the future depending on our leadership availability.
Your Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
male
Female
partners Name
*
First Name
Last Name
Are you and your partner members of TK? (Meaning you have attended consistently for at least a month and are involved in some capacity)
*
Please Select
Yes both of us
No neither
One of us is a member
How long have you been in a committed relationship/marriage?
*
What is your relationship status?
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Happily Married but need to grow
Unhappily married and struggling
Dating
Engaged
Divorced but seeking reconciliation
Seperated
What areas do you feel your relationship could grow in the most?
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Finances/Budget
Communication
Sex life
Love and respect
Scheduling/Calendar conflicts
Parenting conflicts
Blended Family Conflicts
Family Relationships
Setting Healthy Boundaries
Are any of the following currently being experienced in your relationship?
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Affair or unfaithfulness
Addiction (Porn, drugs, alcohol, gambling,etc)
Verbal Abuse
Physical Abuse
Serious Threats or attempts to divorce or separate
parental abuse with kids
sexual abuse
Fits of Rage
None of the Above
Briefly summarize the top 3 issues you would like to address about your relationship?
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What is the area or problem that is MOST difficult for you to speak to your partner about?
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Have you and your partner done couples discipleship in the past? If so when and what was the outcome?
*
Both individuals in the relationship must fill out a separate form to be scheduled for a couples discipleship session. If your partner is not willing to comply, would you like to receive a pastoral care call to seek advice from someone on our pastoral staff on how you can do your part to grow in your relationship?
*
Yes
No
Liability Release: Read carefully and Sign below
Coaching Policy and Liability Release Information about Church Tsidkenu Inc. coaching methods and techniques is available to those who request it. Our coaching is Christian in nature, based upon the Bible. Coaches are encouraged to raise any questions they may have.Coaching CREDENTIALS:The Ministry leaders at Church Tsidkenu are not professionals in psychological counseling, psychiatric therapy, or marriage and family counseling or therapy, and are not licensed by the State of California as counselors, social workers, or therapists.CONFIDENTIALITY STATEMENT:The communications between you and your coach will be considered confidential except to the extent disclosure is required by law or in other instances in which the coach learns of potential threats of harm to self or others, including but not limited to cases of child abuse or neglect, suicide, domestic violence or other violence or physical threats, or homicide. In such instances, your communications may be disclosed to your coach's supervisor or to the Director of the TK Pastoral Care and Coaching Ministry and/or to appropriate state law enforcement authorities. Because this ministry is also a training center, and only with your consent, you may also be assigned a co-leader who is also bound by the duty of confidentiality imposed upon all coaches and leaders in this ministry. In addition, your coach may disclose the written and recorded records of your coaching sessions to his or her leader, clinical consultant, or other counselors to receive supervision regarding your care. By signing this document, you agree to such disclosure for supervision purposes only.MISSED APPOINTMENTS:A counselee who is unable to keep an appointment is asked to call the counseling center office to cancel. Failure to do so may result in termination of counseling. The counselors freely volunteer their time to this Ministry and extensive travel is often required. We appreciate your cooperation in this matter.Disclaimer & Liability Release:I, the undersigned, in consideration of the biblical counseling services provided by Church Tsidkenu Inc., do hereby agree to hold Church Tsidkenu inc., its counseling ministry, and its and their biblical counselors, employees, volunteers, and agents harmless from any and all past, present, future, known and unknown liability, actions, causes of actions, claims, expenses, damages, or injury incurred by me or my property as a direct or indirect result of any counseling services I may receive from Church Tsidkenu Inc., its counseling ministry, or its counselor(s). I have been informed of the nature and purposes of the Bible-based counseling ministry’s services. I understand that confidentiality is not guaranteed and that my consent may be revoked orally or in writing prior to and/or during my counseling session. Furthermore, I understand that neither the lay counselor nor co-counselor to which I am assigned are licensed by the State of California as professional counselors, social workers, financial counselors or advisers, or therapists, and that any desired results are not guaranteed as a result of said biblical counseling services. I further understand that it is the specific intent and purpose of this legally binding document to release, discharge, and indemnify for any and all claims and causes of action of any kind or nature that are directed toward Church Tsidkenu Inc., its counseling ministry, or its counselor(s) in connection with said biblical counseling service or any other associated activities. This includes causes which are known or unknown, specifically mentioned or implied, or neither mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document. I also understand that if any conflicts arise as a result of the counseling services that I receive, I agree to submit such issues to binding Christian arbitration conducted by the National Center for Life and Liberty or another Christian arbitrator and expressly waive any and all rights in law and equity to bring any civil disagreement before a court of law, except that judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. I agree to notify the counseling center office if I am unable to keep an appointment. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of California, and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full Page 3 of 3 legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not mere recitals. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that I have read and understand.
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
*
I agree
Signature
*
What days are you most available to do a couples discipleship session?
*
Monday
Tuesday
Wednesday
Thursday
Friday
saturday
Sunday
What time frames are you most available?
*
Morning 9am-12pm
Early Afternoon 12pm-3pm
Late Afternoon 3pm-6pm
Evening 6pm-9pm
Submit
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