F.L.A.W.L.E.S.S. Intake Form

F.L.A.W.L.E.S.S. Intake Form

First Ladies Anonymous Where Love Encourages Support & Safe Spaces
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How many years have you been in ministry as a First Lady, Pastor, Bishop, etc.?
What state do you currently reside in?
Please select the best option that applies to you
Please select all that applies
Please select ALL that apply:

Other
Have you ever had feelings or thoughts that you no longer want to live?
Do you 'currently' feel that you don't want to live?
How often do you have these thoughts?
Do you feel that you are in a critical point in your life as a wife/First Lady, Pastor, etc.? If so, please explain...
On a scale of 1 to 10, (ten being strongest)do you feel valued as a woman or a woman in ministry?

1

2

3

4

5

6

7

8

9

10

1 is Weak, 10 is Strong

Rows	Yes	No
Are you tired and exhausted when it comes to family life, ministry, work outside/inside the home?
Do you take time out for yourself where you can have down time?
Are there things in your life at this very moment that you would change to be in a better place spiritually, mentally and emotionally?
Do you feel like your current situation is critical and that you are in crisis?

List (as much as you can) all that has transpired that has been burdensome to your heart, your mind and your spirit:
What are you expecting F.L.A.W.L.E.S.S. to do and be in your life?
Signature
Should be Empty: