Counseling Request Intake Questionnaire
If you are interested in pastoral counseling at Lighthouse, please complete the following form.
Date of Birth
State / Province / Region
Postal / Zip Code
Best Phone Number
Please share the best phone number to contact you/leave a message.
How would you prefer that we contact you?
By phone. Below is the best time to call me.
Do you attend Lighthouse on a regular basis?
No. I do not attend church on a regular basis.
No. I attend another church on a regular basis.
Regular basis = at least once a month.
How long have you been attending Lighthouse?
Are you a member of Lighthouse Christian Center?
What is the name of the church you regularly attend?
How long have you been married?
Are you currently living together?
How long have you been living together?
Who will be coming in for the appointment?
I will bring the following people with me:
Do you have children living at home?
Please list your child(ren)'s name(s) and age(s).
Check resources/people who support you.
What prompted you to seek counsel from one of our pastors at this time?
Please share briefly how you believe a pastor can best help you.
What day(s) are best for you to meet with a pastor?
What is the best time of day for you to meet with a pastor?
Thank you for taking the time to provide answers to these questions. A pastor will be contacting you as soon as possible.
PLEASE NOTE: if you get a blank screen after submitting your form, please scroll up to the top of the page. You will be prompted to complete missing fields before resubmitting your form.