Grace Baptist Church - Santa Clarita, California

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Saturday
5:30 & 7:00pm

Sunday
9:00 & 10:45am

Interpreting for the Deaf at the 10:45 service

Grace Baptist Church
22833 Copper Hill Dr.
Santa Clarita, CA
91350
(661) 296-8737
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What do I need to do to get help through Spiritual Care?

You just need to set up an initial appointment.
There are two options to set up an appointment:

Contact the church at 296-8737 ext. 150 / dan.broyles@gracebaptist.org
Complete and submit the following intake form.

Please provide the following contact information:

PERSONAL INFORMATION

First Name:

Last Name:

Age:

Sex:

Marital Status:

Employer:

Position:

Birth Date:

Home Phone #:	ex: 661-123-4567

Mobile Phone #:	ex: 661-123-4567

Address:

E-Mail:

MARRIAGE and FAMILY

Spouse:

Spouse Birth Date:

Spouse Age:

Spouse Occupation:

Spouse Home Phone:

Spouse Business Phone:

Have eitheir you or your spouse been previously married?

If yes to the above question please explain the circumstances:

Children (indicate names, ages, and if they are step children or adopted):

SPIRITUAL LIFE

Do you attend church?

If yes to the above question, where do you attend church?

Are you a member of the church?

Would you describe yourself as a Christian?

If yes, please describe your testimony of becoming a Christian

HEALTH

Describe your health:

List any significant illnesses or injuries:

Physician's Name:

Date of last medical exam:

Report of last medical exam:

Current medications and dosages:

Are you currently seeing, or have you ever seen, a psychiatrist, psychologist or mental health practitioner?:

If so, please explain reasons

BRIEFLY EXPLAIN THE FOLLOWING QUESTIONS

What is the main problem or issue that has brought you here for Spiritual Care?

What have you done about the problem or issue?

What are your expectations for the Spiritual Care Ministry and your time with a Spiritual Caregiver?

Is there any additional information we should know?

Please rate the following concerns on a scale of 1 to 5. 1=no concerns 3=some concerns 5=serious concerns	Spiritual concerns Spiritual Questions Depression Stress Fears Anger Grief Guilty Feelings Suicidal Thoughts Homicidal Thoughts Sleeping Issues Forgiveness Physical Health Issues Parenting Issues Gambling Family Conflicts Marital Issues Poor Self Discipline Inferiority Feelings Pornography Alcohol Use Drug Use Financial Issues Divorce Issues Physical Abuse Sexual Abuse Self Injury Behavior Dating Problems Authority Conflict Poor Social Relationships Legal Issues Loneliness Irritability Strange Thoughts Sexual Issues Other