Ministry Counseling Request Form

Ministry Counseling Request Form

Please fully complete this application to schedule a counseling session. Once you have submitted the form and the release of liability (at the bottom of this application) you will be contacted by an administrator to schedule your session.
Name*

First NameLast Name
Gender*

MaleFemale
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Day Phone*

Area CodePhone Number
What church are you currently attending?*
Requested Date*

MonthDayYear
Date
Requested Time*

:HourMinutesAM/PM Option
Please provide a brief summary of why you are seeking counseling.
Are you requesting counsel from a specific individual? (ie. Pastor Moore, Lady Moore, etc) or anyone available on our counsel team?

These questions are designed to help us assess your needs and potential ministry opportunities. Please answer them truthfully -- it will greatly improve the quality of the ministry you receive at your counseling session.

How would you describe your relationship with the Lord Jesus Christ ?*

	1	2	3	4	5

1 is Distant, 5 is Very intimate

Have you been filled with the Holy Spirit?*

YesNo

I acknowledge that Pastor Moore and or the Pastoral team at Bread of Life Community Church has voluntarily agreed to pray for me.

I understand that this session is not a professional counseling meeting. I understand that he is or they are, to the best of their ability, doing what they can to help me achieve more freedom in my life.

I understand that Bread of Life Community Church is a nonprofit Florida Corporation that does not charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the clergy of this ministry.

I understand that if I receive ministry from the Bread of Life Community Church, the team is committed to respect the disclosed information. I agree to hold Bread of Life Community Church free from any and all liability, loss or damage of any kind that may arise as a result of assistance which I have received.

I have read this disclaimer and release of liability and understand and agree with it and have executed it as my free and voluntary act.
My electronic signature:*

I agree
Type a question*

I understand that my appointment is not confirmed until I receive a follow up email from the Administrative Team confirming the date and time of my counseling session.
Should be Empty: