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    Counseling Request Form: Personal Details

    Uploaded by

    Rebecca Marquez
    This document is a counseling request form collecting personal details about an individual or couple seeking counseling. It requests information such as name, contact details, age, gender, religion, employment/education status, preferred date and time for counseling, and how the individual(s) learned about the counseling service. It also asks about the nature of the counseling concern, whether it is personal, marital, family-related, or other issues. There is a data privacy statement explaining how the information will be used solely for counseling and related pastoral care activities. The individual signs to acknowledge understanding and agreeing to the privacy terms.

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    Counseling Request Form: Personal Details

    Uploaded by

    Rebecca Marquez
    23 views2 pages
    This document is a counseling request form collecting personal details about an individual or couple seeking counseling. It requests information such as name, contact details, age, gender, religion, employment/education status, preferred date and time for counseling, and how the individual(s) learned about the counseling service. It also asks about the nature of the counseling concern, whether it is personal, marital, family-related, or other issues. There is a data privacy statement explaining how the information will be used solely for counseling and related pastoral care activities. The individual signs to acknowledge understanding and agreeing to the privacy terms.

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    This document is a counseling request form collecting personal details about an individual or couple seeking counseling. It requests information such as name, contact details, age, gender, religion, employment/education status, preferred date and time for counseling, and how the individual(s) learned about the counseling service. It also asks about the nature of the counseling concern, whether it is personal, marital, family-related, or other issues. There is a data privacy statement explaining how the information will be used solely for counseling and related pastoral care activities. The individual signs to acknowledge understanding and agreeing to the privacy terms.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    23 views2 pages

    Counseling Request Form: Personal Details

    Uploaded by

    Rebecca Marquez
    This document is a counseling request form collecting personal details about an individual or couple seeking counseling. It requests information such as name, contact details, age, gender, religion, employment/education status, preferred date and time for counseling, and how the individual(s) learned about the counseling service. It also asks about the nature of the counseling concern, whether it is personal, marital, family-related, or other issues. There is a data privacy statement explaining how the information will be used solely for counseling and related pastoral care activities. The individual signs to acknowledge understanding and agreeing to the privacy terms.

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    © All Rights Reserved
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    of 2

    COUNSELING REQUEST FORM

    Date today ___________________


    PERSONAL DETAILS

    If with counseling with partner:


    Name:________________________________

    Tel no (office/home): _____________________


    Name: ___________________________________
    Mobile No. ____________________________
    Tel no (office/home): ________________________
    Age: _______ Sex: _______
    Mobile No. ________________________________
    Status: ___________
    Age: _______ Sex: ________ Status: ___________
    WORKING?  Yes  No
    WORKING?  Yes  No
    STUDYING?  Yes  No
    STUDYING?  Yes  No
    RELIGION? Catholic Buddhist Protestant
    RELIGION? Catholic Buddhist Protestant
     INC Mormon Others: _________________
     INC Mormon Others: _________________
    Attends CCF? Yes  No
    Attends CCF? Yes  No
    D-group Leader (if applicable): ______________
    D-group Leader (if applicable):______________

    NATURE OF THE CONCERN (Pls. check the immediate concern)


     Personal (life’s purpose , Career, friends/officemates)  Professional counseling
     Marital (husband and wife only, Infidelity)  Financial
     Family issues (in-laws, parents, children)  Business
     Relationship (boyfriend/girlfriend, living-in)  Church (beliefs)
     Legal counseling  Others: ______________

    PREFERRED DAY AND TIME : _______________________


    How did you come to know about CCF’s Counseling service?
     Online  DGroup / Small group  Referral  Welcome Center

    In Case of Emergency, pls contact : ______________________________


    The information collected and stored will be used solely for the purposes of the various ministries of
    Pastoral Care Department of CCF, which includes but is not limited to counseling, premarital counseling,
    dedications, deliverance, funeral services, visitations, weddings, renewal of vows and other related
    activities. Changes will only be made upon the collection of updates by CCF Pastoral Care Department
    and/or the request of the participant. Any and all disposal of data will be carried out securely and within
    the timeframe provided by CCF. Information stored or shared to third parties is subject to the privacy
    policy of CCF. The participant waives any and all possible liability upon the disclosure of personal data
    to CCF.
    I hereby affix my signature below as proof that I have read and understood the above Data Privacy
    Statement of CCF and that I agree to the terms and conditions stated therein.
    ___________________________________
    Name and Signature of Requester/Participant

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