EmailMe Form - Water of Life Community Church

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? *

What is your preferred time of day to meet with a caregiver? *

Anytime

Morning

Afternoon

Evening

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