MARRIAGE COUNSELING REQUEST FORM

Marriage / Premarital Counseling Request Form

Complete form below to register for a marriage/premarital counsel session.
At least one name must be filled out! (Husband or Wife or Both)
Fiance / Husband's Full Name*

First NameLast Name
Fiance / Wife's Full Name*

First NameLast Name
What church do you attend?*
YOUR HOME CHURCH
Contact E-mail 1*
Contact E-mail 2
Phone (Primary)*

Area CodePhone Number
Phone (Alternative)

Area CodePhone Number
Please enter your preferred time of session.
*Please note that we generally have sessions in the evening time, rather than in the daytime.
Preferred time?*
Date*

MonthDayYear
Date
Additional Comments:
Please Read Carefully!
Your session is not booked or confirmed. The Administrative Team will review Pastor Keith Moore's schedule and confirm your appointment date/time with you via email as soon as possible. Thank you.
Please check the box if you agree*

I acknowledge that Pastor Keith Moore of Bread of Life Community Church has agreed to pray for me. I understand that this session is based on a biblical worldview. I understand that he is, to the best of his ability, doing what he 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 but receives donations 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 Pastor or ordained clergy of this ministry. I understand that if I receive ministry from 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.
Please check the box if you agree*

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

Marriage / Premarital Counseling Request Form