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Water of Life Community Church
Shepherd Staff Care - Initial Intake Information
1
Personal Information
2
Spousal Information
3
Children
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1
Personal Information
2
Spousal Information
3
Children
Disclaimer: If you are experiencing current suicidal thoughts, please call 911. Water of Life does not offer emergency services.
Are you:
*
WOL Members
WOL Attendees
Neither
I am seeking care for:
*
Self
My Spouse and Me
My Family and Me
Please share the circumstances that are prompting your request for care:
*
Name
*
First
Last
Age
*
Email
*
Cell Phone
*
###
-
###
-
####
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Occupation
*
Are you a Christian?
*
No
Yes, how long?
Do you regularly attend WOL?
*
No
Yes, how long?
Are you currently participating in a Small Group?
*
No
Yes, leader name?
Are you serving in Ministry at WOL?
*
No
Yes, name of ministry?
Marital Status
*
Single
Married
Divorced
Seperated
How many times have you been married?
Are you currently in counseling?
*
No
Yes
Have you previously been in counseling?
*
No
Yes, when and for what?
Are you under a doctor's care for mental health related issues?
*
No
Yes, for what?
Do you use alcohol or drugs?
*
No
Yes, what and how often?
Are you currently having thoughts of harming yourself?
*
No
Yes
If YES - Disclaimer: If you are experiencing current suicidal thoughts, please call 911. Water of Life does not offer emergency services.
Have you ever attempted suicide?
*
No
Yes, date of attempt?
On a typical week, what are your preferred days to meet with a caregiver?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is your preferred time of day to meet with a caregiver?
*
Anytime
Morning
Afternoon
Evening
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