This form will be seen by the Care Staff at Stonegate Church in order to properly assess your care request. By filling out this form, you are giving all Care Staff members permission to view this information. Do you agree? *
Select… Yes No
By choosing yes, I understand that this is not a financial assistance form. This form is designed to help those looking to receive care and counseling within our local community. *
The link for our Mercy Request form can be found here - https://stonegatechurch.churchcenter.com/people/forms/113874
Select… Yes, I understand that this form is not for financial assistance. No
Gender *
Select… Male Female
Phone Number *
Phone type Mobile Home Work Other
Marital Status *
Select… Single Married Widowed Re-Married Never Married Cohabitating Divorced Engaged Separated
Please describe your current relationship to Jesus. *
What does it take to be a Christian? How is your current closeness to God?
How did you hear about this form? *
Select… I was referred by the police department. I am at Stonegate.
Your Current Struggle *
Check all boxes below that describe your current struggle:
Please feel free to expand with details on any of the boxes that you checked above.
Briefly describe what you feel is the "main" issue you are struggling with.
Briefly describe why you have chosen to seek counseling.
What type of person are you hoping to meet with? *
We will not always be able to completely fulfill your expectations, but through the assessment process, it will help us to know who would be best for you to meet​ with.
What do you hope to achieve throughout the counseling process?
Have you discussed your current situation or struggle with your Home Group Leader(s) or people in your community? *
Select… Yes No
Are there any additional details about your community situation that would be helpful for us to know? Do you have a support system around you?
Are you currently seeing a licensed counselor, psychologist, psychiatrist or a pastor at Stonegate? *
Medical Note - Please list all prescription medications and any over the counter medications you are taking: *
Please use this space to communicate any further information you want us to know:
Please Read the Following Statement and Check the Box below if You Agree *
I have thoroughly read and agree to the foregoing policies regarding pastoral care provided at Stonegate Church. I hereby release and hold harmless Stonegate Church, its directors, officers, employees, and volunteers from any and all liability, claims, and/or expenses related to or arising from any pastoral care or counseling received (or not received).
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