COUNSELING REQUEST

COUNSELING REQUEST FORM

Our Pastoral Care Team assists Element Church members through Biblical counseling for issues involving marriage, family, emotional, spiritual and other life challenges. We are not state-licensed counselors, but we can assist you in resolving minor conflicts or refer you to a professional as needed. Please fill out the following questions to get the process started.

- Step 1 of 3

PERSONAL INFORMATION

Name *

First

Last

Phone *

Email *

Gender *

Male
Female

Are you married? *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

CHURCH AFFILIATION

Do you attend Element Church on a regular basis? If so, which campus? *

Online
Wentzville
St. Charles
No, I don't attend regularly

How often do you attend? *

Weekly
Once or Twice a Month
Occasionally
Never- I don't attend

Do you give regularly at Element Church? *

Are you currently volunteering at Element Church? *

Are you currently in an Element Church Small Group? *

Who referred you to the Pastoral Care Team for counseling?

COUNSELING REQUEST DETAILSPlease tell us about your situation.

What type of counseling are you primarily seeking? *

Marriage Counseling
Pre-Marital Counseling (marriage prep)
Relationship Counseling (not married)
Grief Counseling
Family/Parental Counseling
Other (please list below)

Other *

If we are able to help you, what times typically work best for you? *

Mornings
Afternoons

Have you received counseling from Element Church or ANY other ministry or agency during the past 6 months? *

Submitting this questionnaire does not guarantee you will receive counseling from our Pastoral Team. We will review the information you provided and let you know if further information is needed. Thank you!

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100 MALL PARKWAY SUITE 500 WENTZVILLE, MO 63385

636.332.9010

OFFICE@ELEMENTCHURCH.COM