Client Information Request Form - Soul Care Services by John

Client Information Request Form - Soul Care Services by John

please fill out a new form to request starting services or to request adding another service
Next Steps

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HOW TO HIRE DR. JOHN

Step one: When you fill out this form, you are sharing your need with Dr. John. A discussion around how to proceed will follow.

When you are subsequently meeting with John or he has provided the requested service for a loved one, John will send you an email invitation to make payment. This is step two which repeats each time a service has been provided.

When you open your email from Dr. John and remit payment, you will have completed the final step, step three.

When the agreed upon number of sessions or services have concluded or when you have a different matter for which you would like to hire Dr. John to help with, kindly start by filling out this form to hire Dr. John again.

All counseling/coaching is provided by John Blackburn DRS, PCLC for the hourly fee amount of $110 per session, unless otherwise determined.
Requested services are for:

myself as an Individual for life coachingan engaged couple counselinga married couple counselingchaplaincy home visit for a family member or friendchaplaincy during loss of loved onea home Bible study group teachinga congregation interim needan event based speaking engagementOther

Single Life Coach Section
All this information is held in strictest confidence and will be kept on file for reference only by John Blackburn DRS, PCLC, your counselor/coach.
Name

First NameLast Name
Marital Status

SingleMarriedDivorced
Date of Birth

MonthDayYear
What is the main issue(s) or reasons that bring you here for counseling-coaching?
Is there any other pertinent information that Dr. John should know that may relate to this counseling-coaching process ? If so, please explain:
Please read and sign below if you agree with the following terms of the counseling/coaching process:
1. At any time during the counseling process, for reasons sufficient to himself, it is John’s – as also your – prerogative to terminate the counseling/coaching relationship.
2. All counseling/coaching is provided by John Blackburn DRS, PCLC for the hourly fee amount of $110 per session, unless otherwise determined.
3. You as the client are held fully responsible for how you apply and
  implement the advice and counsel you receive from your counselor / coach.
I have read the above terms and agree to partner with Dr. John Blackburn of Soul Care Services LLC in the counseling/coaching he provides in accordance with said terms.
Signature

Clear
Date

MonthDayYear
Date
Hour MinutesAM/PM Option

Married Couple's Section
By providing this information, you are allowing Dr. John to better understand your past and current marital and family status, as well as maintain contact with you as a couple. All information is held in strictest confidence and will be kept on file for reference only by your counselor/coach, Dr. John Blackburn.
Husband's Name

First NameLast Name
Husband's Date of Birth

MonthDayYear
Date
Husband's Email
name@example.com
Husband's Phone Number
Please enter a valid phone number.
Please read and sign below if you agree with the following terms of the counseling/coaching process:
1. At any time during the counseling process, for reasons sufficient to himself, it is John’s – as also your – prerogative to terminate the counseling/coaching relationship.
2. All counseling/coaching is provided by John Blackburn DRS, PCLC for the hourly fee amount of $110 per session, unless otherwise determined.
3. You as the client are held fully responsible for how you apply and
  implement the advice and counsel you receive from your counselor / coach.
I have read the above terms and agree to partner with Dr. John Blackburn of Soul Care Services LLC in the counseling/coaching he provides in accordance with said terms.
Husband's Signature

Clear
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Wife's Name

First NameLast Name
Wife's Date of Birth

MonthDayYear
Date
Wife's Email
name@example.com
Wife's Phone Number
Please enter a valid phone number.
Please read and sign below if you agree with the following terms of the counseling/coaching process:
1. At any time during the counseling process, for reasons sufficient to himself, it is John’s – as also your – prerogative to terminate the counseling/coaching relationship.
2. All counseling/coaching is provided by John Blackburn DRS, PCLC for the hourly fee amount of $110 per session, unless otherwise determined.
3. You as the client are held fully responsible for how you apply and
  implement the advice and counsel you receive from your counselor / coach.
I have read the above terms and agree to partner with Dr. John Blackburn of Soul Care Services LLC in the counseling/coaching he provides in accordance with said terms.
Wife's Signature

Clear
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
How long have you been married?
Have either of you been previously married?
Do you have any children? If so, how many?
Is there any other pertinent information that Dr. John should know that may relate to this counseling process and/or your marriage relationship itself? If so, please explain:

Engaged Couple's Section
To be Wife's Name

First NameLast Name
To be Husband's Name

First NameLast Name

Church - other Section
Entity Name
Business, Group, Nickname or Couple's Name
Please comment further here about your request of John.

Chaplaincy Section
Please let Dr. John know of your Chaplaincy need here.

Select to Continue Section
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add contact information

Contact Information Section
If you have already filled in similar information earlier in this form, kindly help Dr. John know the primary contact person by filling this section out as well please. This is especially useful by example, when one spouse doesn't check email regularly - the service request is for an aging parent - a church or entity is hiring John for an event or service. Thank you for understanding.
My Name
PRIMARY CONTACT PERSON
My role or purpose relating to John's services
I am the spouse, father, wife, daughter, funeral home director, church liaison, etc.
My Email
PRIMARY CONTACT PERSON
My Phone Number
PRIMARY CONTACT PERSON
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
File Upload

attach any format of contact list as a set
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