Water of Life Community Church


Welcome to Water of Life Healing/Caring Ministry


Thank you for taking a few moments of your time to help us expedite your counseling request.
Please fill out the form below as completely as you can; your answers are confidential.
 
We will begin processing your counseling request as soon as we receive it. We receive the requests during our regular business hours; Monday through Thursday from 9 A.M. to 5 P.M.
 
If your situation is an emergency, please dial 911. This is not a crisis hotline.
 
You will receive a follow-up phone call upon our receipt of your submitted request.

Intake Form

Counseling Type:
Full Name: Age:
Phone: Email Address:
City You Live In: Marital Status:

Spouse Full Name: Spouse Age:
Married How Long (in Years): Divorced How Long (in Years):
Separated How Long: Her Marriage:
His Marriage:

First Child Name: First Child Age:
First Child Gender: First Child Status:
Second Child Name: Second Child Age:
Second Child Gender: Second Child Status:
Third Child Name: Third Child Age:
Third Child Gender: Third Child Status:
Fourth Child Name: Fourth Child Age:
Fourth Child Gender: Fourth Child Status:
Fifth Child Name: Fifth Child Age:
Fifth Child Gender: Fifth Child Status:
Sixth Child Name: Sixth Child Age:
Sixth Child Gender: Sixth Child Status:

Are you a Christian: Is your spouse a Christian:
Are you currently in Counseling:
Do you attend Water of Life Community Church:
Your Primary Reason for Visit:
Your Secondary Reason for Visit: