Posted on 01/29/202001/29/2020 by Chris BassConsultation 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 No Are you a member of Shores? Yes No How did you hear about our counseling services? Do you belong to another church? Yes No If yes, please provide your church's name and phone number If yes, does your pastor know that you are seeking outside help? Yes No If no, please explain why not? Please provide your Pastor's Name and contact information Are you under a doctor's care Yes No If yes, what reason? What medications are you currently taking? Marrital Status Married Unmarried Separated Divorced Number of children in the home and ages In case of emergency, please provide contact information (Name, Telephone, Relationship) FOR OFFICE USE ONLY Consultation approved by: __________________________________________ Assigned to: __________________________________________ From 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM To 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Consultation to take place at (Location) It is hereby acknowledged by the said parties that the above consultation took place at the mutual agreement of said parties. This consultation is based on spiritual principles and that parties are aware that they are not being advice from a Medical professional or Licenses Therapist but a Licenses Elder of Shores Baptist Worship Center. It is also acknowledged that as Leaders of Shores Baptist Worship Center it is our responsibility to advise you according to the Gospel of Jesus Christ with sound judgment and Godly wisdom. However, it is also acknowledged that the final decision is the sole responsibility of the one (s) seeking consultation. And, the person signing this contract will not hold Shores Baptist Worship Center nor the Representative of Shores Baptist Worship Center liable for any decisions made based on the spiritual consultation received. Signature of Fresh Wind Ministries Representative Date Signature Print Name Date Signature Print Name Date reCAPTCHA If you are human, leave this field blank.