Care & Counseling Intake Form

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If you are seeking emotional, mental, relational, physical or spiritual care in either a private or group setting fill the form below.

First & Last Name *

Address *

Birthday *

年

月

日

If you are a minor please include your parents contact information:

Gender *

Phone Number *

Emergency Contact and Phone Number *

Email Address *

What is your availability? *

Number of household members *

Are you currently employed *

Yes

What is your profession?

Do you attend EFCC? *

Yes

How did you hear about Emmanuel Faith Care & Counseling? *

I am already connected to the following EFCC Staff Member:

Would you like to continue meeting with the above mentioned Pastor/Director

Yes

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How urgent is your issue? *

Not Urgent

Very Urgent

Please describe briefly the circumstances that led you to reach out to Care & Counseling. *

I hope to receive help through the following: *

Counseling

Mentoring

Support Group

Care

Financial Support

其他:

If selected "Other" please explain below

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切勿通过 Google 表单提交密码。

此表单是在 Emmanuel Faith Community Church 内部创建的。举报滥用行为