Date:
Name:
Address:
City/State/Zip:
Phone (Home):
Phone (Work):
eMail Address:
Fax:
Church:
Address:
City/State/Zip:
Phone:
Pastor:
Marital Status:
Single
Married
Divorced
Spouse's Name:
Children:
Yes
No
Names:
Referred by:
Briefly describe your relationship with God.
Have you had ministry or help for this problem or a related problem before? Describe.
Why are you coming to Klesis for ministry?
What would you like to see happen from our work together? (Be specific)
Have you sought help from other counselors in the past about this problem? Who?
Would you like to receive our free newsletter (The Klesis Quarterly)?
Yes
No
