Pastoral counseling inquiry

Your information

Name

Birthdate

Mobile Phone

Preferred contact method

Best time to reach you

Preferred language

Pastor preference

Emergency contact

Name

Relationship

Phone

Church relationship

Are you part of our congregation?

Faith background

What brings you here?

Areas you'd like support with (check all that apply)

In your own words, what would you like help with?

How long has this been a concern?

How urgent does it feel?

Background

Have you received counseling before?

Currently working with a therapist?

Anything about your medical or mental health history you'd like us to know? (optional)

Faith and prayer

How would you describe your relationship with God right now?

How would you like faith integrated?

Wellbeing check

These questions help us care for you well. Please answer honestly — there's no judgment here.

I am currently safe in my home and relationships.

I have had thoughts of harming myself or someone else recently.

I am open to being referred to a licensed counselor if pastoral care alone is not enough.

Consent and acknowledgment

Checkbox

I understand pastoral counseling offers spiritual guidance and support, and is not a substitute for licensed mental-health treatment or medical care.

I understand confidentiality is held in pastoral trust, except where reporting is required by law (abuse of a child or vulnerable adult, imminent harm to self or others).

I consent to being contacted at the email or phone number above.

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Date

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