Counseling Request Form

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Contact Information – Step 1 of 3

Entry Date *

Today’s Date

First Name *

Last Name *

Gender *

Male
Female

Age Group *

13-18
19-35
36 -50
51 & Above

Marital Status *

Single
Married
Divorced / Separated
Widow / Widower

Phone *

Email *

Preferred Contact Time *

Please indicate your current time zone and your available timeframe for an appointment.

Select Your Current Time Zone *

Preferred Contact Method *

Phone
Email
In Person
Video Conference Call (Zoom, Teams)

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Which area(s) best describe what you’d like counselling/mentorship for? *

Spiritual Growth & Intervention
Academics
Mental Health
Talent Development & Others

Select what you’d like counselling/mentorship for? *

Spiritual Growth & Intervention
Pre Marital Counseling
Marriage Counseling
Family & Parenting
Academics
Mental Health
Talent Development & Others
Career & Workspace
Entrepreneurship & Financial Empowerment

Section A: Background

Date of Birth *

Wedding Date *

Length of Marriage *

How many children do you have together? *

if none, enter 0

Are you Born Again? *

Year of Salvation: *

Year of Baptism: *

Name of Church: *

Name of Pastor: *

Describe Your Salvation Experience *

If applicable (few words)

Were you married before this marriage? *

Is your "EX" living?

Where does your "EX" reside/live

Country, region/state

When did you divorce your "EX"

Number of children outside of the marriage

If none, enter 0

Any affair unknown to your spouse *

Occupation *

Employer *

SECTION B: X-RAY

On a scale of 0-3, which of these issues listed below are prevalent in your marriage. 0 = “Not at all”, 1 = “Mild”, 2 = “Very Much So”, 3 = “Terrible”

Secrecy *

Communication Gaps *

Declining Sexual Intimacy *

Infidelity *

Fighting About Money *

Declining Appreciation & Love *

In-Laws Interference *

Lack of Quality Time *

Abuse: Emotional / Physical *

Lack of Respect *

Conflicts From Parenting *

Emotions

On a scale of 0-3, which of the following emotions are prevalent in your marriage. 0=”Not at all” , 1= “Mild”, 2= “Very Much So”, 3= “Terrible”

Anger *

Malice *

Depression *

Stress *

Fear *

Anxiety *

Hatred *

Premarital in all

Were you happy at any time in this marriage? *

If Yes, Why and What Changed

Do you feel occasionally threatened or scared living with your spouse? *

Do you have daily devotional together? *

Seldom / Rarely
Often / Daily
Not At All

Section C : Dream

List your Top 3 Desires and Expectations from this counseling session *

In your evaluation, list the Top 5 things your spouse must begin to do for a turnaround in your marriage *

List the efforts you have taken to see improvements in your relationship with your spouse *

Is divorce an option for you? *

If divorce is an option, please explain

Financial Section

What's your main financial concern at the moment?

Debt
Budgeting
Job Loss
Business Stress
Other

What goal would you like to achieve through counseling?

How would you describe your current money habits ?

(saving, budgeting, giving, etc.)

Is there any urgent financial matter that needs attention?

What's your current work or business situation?

Employed
Seeking Employment
Transitioning / Career Change
Self Employed

What challenge are you facing at work right now

Burnout
Direction
Workplace Conflict
Lack of Growth

How satisfied are you with your career path

What outcome do you hope to get from counselling

Are you born again ? *

Religion *

Christianity
Islam
Occultic / Satanist
Agnostic

Year of Baptism *

N/A (if not applicable)

Year of salvation *

N/A (if not applicable)

Name of pastor *

Name of church *

Salvation Experience

Describe your salvation experience in a few words (If applicable)

What do you think could be the root of your fears, if relevant to you? *

Fear has a root in what you hear, see, know or do.

Are you aware of any secret sin? *

The accuser of brethren, Satan has a ground to torment when there is a secret sin.

Will you say your time in the study and meditation of the word of God is high or low? *

Low
High

The Word of God is a powerful weapon in spiritual warfare.

Is the Holy Spirit convicting you to make certain confessions ? *

The Holy Spirit convicts Believers to make certain confessions. Do you have any such experience?

If Yes, details of the conviction of the Holy Spirit?

The Holy Spirit convicts Believers to make certain confessions. Do you have any such experience? If yes, please provide details.

Do you have dreams or patterns that are frightening ? *

Are you in right standing with God, or do you need to rededicate your life to God ?. *

Yes (Right Standing)
No (Rededicate To God)

What is your salvation journey like ? Will you say you are in right standing with God, or do you need to rededicate your life to God.

How is your prayer life lately? *

Great
So, So
Terrible

Have you gone for a deliverance session before ? *

If Yes, provide deliverance details.

Please provide details of previous deliverance sessions.

Are you aware of any evil or negative patterns in your family ? *

If Yes, provide details of evil or negative patterns.

Please provide details of evil or negative patterns. Are you aware have any evil or negative patterns in your family ?

Please provide any further information that may assist the counselor address your needs. *

What family or parenting issue are you seeking help with?

Communication
Discipline
Conflict
Other

What are the ages of the children involved?

How would you describe your family dynamics right now?

Have there been any recent changes or challenges at home?

Move
Loss
Separation / Divorce
New child
Other

Briefly describe what you'd like to discuss

How long has this been a concern for you?

What have you tried so far to address it?

How is this situation affecting your life or relationships?

What grade are you currently in?

What areas are you finding most challenging?

Motivation
Focus
Grades
Peer Pressure
Direction
Other

How do you feel about school right now?

What kind of help would you like?

Academic Planning
Motivation
Prayer
Mentorship

How have you been feeling emotionally lately?

Anxious
Sad
Overwhelmed
Numb
Other

Other emotions / feelings

If other, please sprecify

Have you experienced any major changes or losses recently?

Do you have someone you can talk to for support?

Do you feel safe right now?

Part A: Background

Current Marital Status

Single
Married
Widowed
Divorced

Name of EX

Date Divorced

Number of children?

How many children do you have with your “ex” or deceased partner. If none, enter 0

Date of Death

EX in USA?

If No, where does your EX reside

Name of Fiancée *

First

Last

Fiancée in USA ?

If no, where ?

Please specify the country / region

Your Current Employer

Your Genotype

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Part B: Faith

Are You Born Again ?

When – born again?

Date you gave your life to Christ

Where – born again?

Are you water baptized?

When – water baptized?

Date of water baptism

Where – water baptized

Are you baptized in the Holy Spirit?

When – holy spirit baptized?

Date of holy spirit baptism

Where – holy spirit baptized

Are you a member of RCCG – The King's Palace

Since When?

Date you joined RCCG TKP

Name of Church / Denomination

Are you a church worker?

When?

Date you joined a team / ministry

What ministry / department?

Part C: Relationship

When did you meet your fiancée

Have you started courtship?

If Yes, when?

Do you have parental consent?

Have you had traditional wedding?

When was the traditional wedding?

Date of traditional wedding

Any premarital counseling?

Have you had court wedding?

When was the court wedding?

Date of court wedding

Do you share Apartment / Home?

Proposed Date of Church Wedding

Date

Time

Will that be in RCCG – The King's Palace?

If No, Where?

Do you know of any reasons you or anyone else may have – why you may not be joined in Holy Matrimony with your fiancée?

If Yes, are you willing to discuss that with pastor?

Will you abide by all church regulations on church wedding?

Signature

Clear Signature

Date Signed *

File Upload

Note: Please attach to this form in minimum 50 Words 1. Your conviction going into this relationship, 2. Your salvation experience, 3. Any family evil pattern of concern, 4. Parental consent, 5. Medical concern that may impact the marriage

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Have you received counselling / mentorship on this before? *

If Yes, what steps have already been taken?

Urgency of request *

Normal
Urgent
High Priority (crisis)

Do you understand your information is confidential, with exceptions for safety / legal reasons? *

Do you consent to be contacted within 24-48 hours? *

Data Privacy Agreement *

I consent to the collection and use of the information I have submitted, so it can be reviewed and used to respond to my counseling request.

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