Spiritual Care Form

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:
1. Contact the church at 296-8737 ext. 150 or email Dan Broyles
2. Complete and submit the following intake form.

Please provide the following info:

First Name*
Last Name*
Address*
Home Phone
Mobile Phone
Email Address
Age*
Birthdate*
Gender*
Marital Status*
Employer*
Occupation*
Emergency Contact:
Phone
Relationship to you
Has an intake appointment already been scheduled?*
How did you hear about Spiritual Care?
Day/Time availability during the week to meet with a Care Giver:
Spouse
Spouse Birth Date
Spouse Occupation
Spouse Phone
Have either you or your spouse been previously married?
If yes to above please explain
Children (names, ages, biological, step, adopted, foster)
Do you attend church?*
If yes to above, where?
Are you a member of that church?
Would you describe yourself as a christian?*
If yes, please describe your testimony of coming to Christ
Briefly describe your health*
List any signifigant illness or injury
Physician's Name
Date of last medical exam
Report of last medical exam
Current medications and dosages
Are you currently or have you ever seen a psychiatrist, psycologost or mental health professional?*
If yes, please explain reasons
What is the main issue that has brought you here for Spiritual Care?*
What have you done about this issue?*
What are your expectations for the Spiritual Care Ministry and your time with a Spiritual Caregiver?*
Please share any additional information we should know?
Level of Concern with following Issues (Rate 0-5) 0=No Concern, 5=Serious Concern
Spiritual
Depression
Stress
Fear
Anger
Grief
Guilt
Suicidal Thoughts
Homicidal Thoughts
Sleep Trouble
Forgiveness
Physical Health
Parenting
Gambling
Family
Marriage
Poor Self Discipline
Inferiority Feelings
Pornography
Alcohol Use
Drug Use
Financial
Sexual Abuse
Self Injury Behavior
Dating Problems
Authority Conflict
Poor Social Relationships
Legal Issues
Loneliness
Anxiety
Irritability
Strange Thoughts
Sexual Issues
Hopelessness
Impact of miscarriage or abortion
Any other area not listed (please indicate level of concern)
Please answer the simple math question below to submit the form.
2 + 2 =