Blaze Christian Fellowship

First Name

Last Name

Birthdate

Gender

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Employer / Occupation

Work Number

Counselor's Name

Date

If you can't remember exactly, make an estimated guess.

Have you had ANY counseling before?

No

Yes

What problem brings you here today?

What do you expect from counseling?

Are there any recent changes in your life or any other information that we should know about?

I realize that the counselors at Blaze Christian Fellowship are not professional psychiatrists or psychologists, and that their counsel is based on God’s Word, alone. I also recognize that I am solely responsible for my own actions. I therefore agree, that I will not hold Blaze Christian Fellowship, its staff, or my counselor responsible or liable for anything whatsoever, connected with the counsel that I receive. I understand that my visit is confidential to the highest point biblically allowable.

Signature

Counseling