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