REQUEST TO RECEIVE PEER COUNSELING

Contact Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can we text you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is email a good way to contact you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you need a spanish speaking counselor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Personal Informaiton

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Previous Marriages? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have any children? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Availability for Peer Counseling

Mornings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Afternoons {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Evenings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spiritual Life

Would you describe yourself as a Christian? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you attend the Desert Vineyard? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you attend a church? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physical and Mental Health

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Are you currently or have you ever seen a psychiatrist, psychologist or other mental health professional? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently or have you ever been part of a drug or alcohol treatment program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you currently have a sponsor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Counseling Information

Have you ever had peer counseling before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is this counseling request court-related in any way, including, but not limited to, a parole or Department of Children and Family Services (DCFS) requirement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Personal Inventory

Please rate your level of concern (0-5) with the following issues.  (0=No Concern, to 5=Serious Concern)

Spiritual {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stress {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fear {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Anger {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Grief {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Guilt {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Suicidal Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Homicidal Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Forgiveness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physical Health {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sleep Trouble {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Parenting {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gambling {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Family {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Marriage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Poor Self Discipline {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Inferiortiy Feelings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pornography {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Alcohol Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Drug Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Financial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sexual Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Self Injury Behavior {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dating Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Authority Conflict {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Poor Social Relationships {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Legal Issues {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Loneliness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Irritability {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Strange Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sexual Issues {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Shame {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please type your full name and date, stating that you have read this full form and are committed to this process as a peer counselee.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Thank you for applying for Peer Counseling at the Desert Vineyard. We will conact to you to discuss your application after it has been reviewed.

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REQUEST TO RECEIVE PEER COUNSELING

REQUEST TO RECEIVE PEER COUNSELING

Contact Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can we text you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is email a good way to contact you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you hear about peer counseling? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you need a spanish speaking counselor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Personal Informaiton

Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Occuption {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Marital Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spouses Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How long have you been married? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Previous Marriages? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are there any important details from your previous marriage(s) you think we should know? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have any children? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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List the names, ages and any important information about your children (special needs, adopted, step, foster etc.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Availability for Peer Counseling

Mornings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Afternoons {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Evenings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spiritual Life

Would you describe yourself as a Christian? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you have been baptized, include that date here {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Briefly describe how you came to Christ. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you attend the Desert Vineyard? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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For how long have you attended? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you attend a church? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Where do you attend? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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For how long have you attended? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you serve at your church or in the community, what do you do? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physical and Mental Health

How would you describe your general health? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have any significant illnesses or injuries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physcians Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of last medical exam: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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List current mediations, their purpose and the dosage. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently or have you ever seen a psychiatrist, psychologist or other mental health professional? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please exlain the reason: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently or have you ever been part of a drug or alcohol treatment program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you currently have a sponsor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Counseling Information

Have you ever had peer counseling before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did that previous peer counseling go for you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the main issue for which you are seeking help? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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When did you first notice this issue in your life? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What have you done about this issue? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What are your expectations for Peer Counseling? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please share any other information about you we should know: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is this counseling request court-related in any way, including, but not limited to, a parole or Department of Children and Family Services (DCFS) requirement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Personal Inventory

Please rate your level of concern (0-5) with the following issues.  (0=No Concern, to 5=Serious Concern)

Spiritual {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Stress {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Fear {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Anger {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Grief {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Guilt {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Suicidal Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Homicidal Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Forgiveness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Physical Health {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sleep Trouble {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parenting {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gambling {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Family {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Marriage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Poor Self Discipline {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Inferiortiy Feelings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Pornography {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Alcohol Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Drug Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Financial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sexual Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Self Injury Behavior {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Dating Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Authority Conflict {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Poor Social Relationships {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Legal Issues {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Loneliness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Irritability {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Strange Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Sexual Issues {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Shame {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Any other area not listed? (Include rating) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please type your full name and date, stating that you have read this full form and are committed to this process as a peer counselee.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Thank you for applying for Peer Counseling at the Desert Vineyard. We will conact to you to discuss your application after it has been reviewed.

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