Consultation Request

Today's Date

What do you need counseling for?

First Name *

First

Last Name *

Last

Email *

Home Phone Number *

Cellular Phone *

Best time to contact you? Home or Cell?

Have you accepted Jesus Christ as your personal Savior?

Yes

Are you a member of Shores?

Yes

How did you hear about our counseling services?

Do you belong to another church?

Yes

If yes, please provide your church's name and phone number

If yes, does your pastor know that you are seeking outside help?

Yes

If no, please explain why not?

Please provide your Pastor's Name and contact information

Are you under a doctor's care

Yes

If yes, what reason?

What medications are you currently taking?

Marrital Status

Number of children in the home and ages

In case of emergency, please provide contact information (Name, Telephone, Relationship)

FOR OFFICE USE ONLY

From

Consultation to take place at (Location)

Signature of Fresh Wind Ministries Representative

Date

Signature

Print Name

Date

Signature

Print Name

Date

reCAPTCHA

If you are human, leave this field blank.

Shores Baptist Worship Center