Application for Counseling Assistance • The Western Conference

This will ONLY be viewed by the Board of Pastoral Health Chairman and Western Conference Assistant Superintendant.

First Name *

Last Name *

Complete Home Address *

Email Address *

Phone Number *

Type of Counseling *

Marriage

Personal

Family

Other

If other, please describe

Brief explanation of need for counseling: *

What steps have you taken to resolve this issue? *

Have you participated in counseling for this reason before? *

Yes

If yes, please explain:

Do you have a Counselor or would you like a recommendation? *

Please Recommend A Counselor

I Have A Counselor

Name of Counselor

Estimated timeframe for counseling: *

Cost of Counseling ($ Value): *

Funds you are investing ($ Value): *

Insurance Providing ($ Value): *

Funds Provided By The Local Church ($ Value): *

Funds Requested From The Board of Pastoral Health ($ Value): *

If approved, when are the funds needed? *

Where should funds be sent (Church or Counselor/Address): *

Signature *

Tip: Please provide your full legal name in the signature box

Date of "Signature"