McCook Christian Church Pastoral Care Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Windowed
Engaged
Divorced/Separated
Employer
Position
Emergency Contact
First Name
Last Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Marriage and Family
Spouse
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
Occupation
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have either you or your spouse been previously married?
Yes
No
If so, please explain the circumstances.
Children (Indicate names, ages, and if they are step children or adopted)
Spiritual Life
Would you describe yourself as a Christian?
Yes
No
If yes, please briefly describe your testimony of becoming a Christian.
Do you attend church?
Yes
No
If so, what church and what involvement do you have in the church?
Are you a member of the church?
Yes
No
Briefly explain the following questions.
What is the main problem or issue that has brought you here for Spiritual Care?
What have you done about the problem or issue?
What are your expectations for the Spiritual Care Ministry and your time with a Spiritual Caregiver?
Is there any additional information we should know?
Rate each issues (0-5) 0=no concerns; 3=some concerns; 5=serious concerns
Spiritual Concerns
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Spiritual Confusion
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Depressed Feelings
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Anxiety Feelings
no concerns
1
2
3
4
serious concerns
5
1 is no concerns, 5 is serious concerns
Fears
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Anger
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Grief
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Guilty Feelings
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Suicidal Thoughts
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Homicidal thoughts
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Sleeping Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Forgiveness
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Stress
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Physical Health Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Parenting Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Gambling
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Family Conflicts
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Marital Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Poor Self Discipline
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Inferiority Feelings
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Pornography
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Alcohol Use
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Drug Use
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Financial Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Divorce Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Panic Thoughts
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Physical Abuse
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Sexual Abuse
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Self Injury Behavior
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Dating Problems
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Authority Conflict
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Poor Social Relations
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Legal Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Loneliness
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Irritability
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Strange Thoughts
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Sexual Issues
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Lack Confidence
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Other
no concerns
0
1
2
3
4
serious concerns
5
0 is no concerns, 5 is serious concerns
Submit
Should be Empty: