REQUEST TO RECEIVE PEER COUNSELING

Contact Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Can we text you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is email a good way to contact you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How did you hear about peer counseling? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you need a spanish speaking counselor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Personal Informaiton

Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Occuption {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spouses Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long have you been married? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Previous Marriages? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are there any important details from your previous marriage(s) you think we should know? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you have any children? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

List the names, ages and any important information about your children (special needs, adopted, step, foster etc.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Availability for Peer Counseling

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

Spiritual Life

Would you describe yourself as a Christian? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have been baptized, include that date here {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Briefly describe how you came to Christ. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you attend the Desert Vineyard? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

For how long have you attended? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you attend a church? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Where do you attend? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

For how long have you attended? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you serve at your church or in the community, what do you do? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Physical and Mental Health

How would you describe your general health? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you have any significant illnesses or injuries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Physcians Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last medical exam: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

List current mediations, their purpose and the dosage. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Are you currently or have you ever seen a psychiatrist, psychologist or other mental health professional? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please exlain the reason: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently or have you ever been part of a drug or alcohol treatment program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you currently have a sponsor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Counseling Information

Have you ever had peer counseling before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How did that previous peer counseling go for you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the main issue for which you are seeking help? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

When did you first notice this issue in your life? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What have you done about this issue? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

What are your expectations for Peer Counseling? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please share any other information about you we should know: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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 }

{binding displayValue}

Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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}

Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Stress {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fear {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Anger {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Grief {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Guilt {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Suicidal Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Homicidal Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Forgiveness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Physical Health {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sleep Trouble {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Parenting {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gambling {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Family {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Marriage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Poor Self Discipline {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Inferiortiy Feelings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pornography {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Alcohol Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Drug Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Financial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sexual Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Self Injury Behavior {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dating Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Authority Conflict {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Poor Social Relationships {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Legal Issues {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Loneliness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Irritability {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Strange Thoughts {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sexual Issues {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Shame {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Any other area not listed? (Include rating) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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 }

{binding displayValue}

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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.