Live Fully Engaged Ministries » Individual/Child/Teen Form

Individual/Child/Teen Form

General Information

Your Name(required)

Address(required)

City(required)

State(required)

Zip code(required)

Phone - Home(required)

Phone - Cell(required)

Phone - Work(required)

Fax

Email(valid email required)

Please Repeat Email(valid email required)

Marital Status

Single Married Separated Divorced Widowed

If married, how many years?

If divorced, how many years?

Have you ever been in counseling? If yes when?

Are you now in counseling? If yes how long?

With whom are you counseling?

If you were referred, by whom?

Briefly describe what you would like to accomplish in counseling:

Briefly describe your original family

Do you regularly use legal or illegal medications? Alcohol?

Describe

By my signature below, I agree that I am committed
to coming and working on my individual issues. Also,
I understand that it is required that I not bring other family
members with me to this appointment unless it is suggested by LFEM or I am a parent coming with my child/teen.

Input your full name to sign this form

Signature

Date

Human Verification

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