Thank you for inquiring within my office for an appointment. It is my sincere desire to see the families in this generation strengthened through wise decisions and their faith in Christ solidified through practical help.

I want to make sure that you can get the answers you need, so in order to accommodate that, I must request that you complete just a few simple questions and press "SUBMIT" at the end of this questionnaire. Your request will come directly to my office and will be kept in the strictest of confidence with the help of my scheduling secretary, Mrs. Jean McCollam, and my counseling pastor, Dr. Dave Douglass.

I would like for everyone to obtain the individual attention they deserve; however, it is my ultimate goal that each individual obtain the wisdom he needs. I am humbled that you would take the time to request some advice. It is a privilege to pastor such a great people. Thank you for taking the time to respectfully complete this questionnaire.

Your Pastor,

Full name
Have you sought prior counsel with this issue? --Select-- Yes No With whom?

 

Please check all that apply, describing why you would like an appointment:

Anointing with Oil Picture With Baby Wedding Date

Relationship Counseling Premarital Have you taken Dr. Bob Marshall's class "Preparing for Marriage" during our Sunday night 6:00 p.m. TNT time? No Yes Marital Re-Marital Dating Parental Children Other
Recovery Counseling Divorce Addiction Sexual Abuse Physical Abuse Other
Emotional Health Counseling Anxiety Depression Grief/Loss Anger Management Other
Physical Health Counseling Uninsured With Poor Health Describe Symptoms Below Other
Addiction Counseling Alcohol/Narcotics Tobacco Gambling Sexual Other
Miscellaneous Counseling Financial Legal Advice Business Advice Pastor Needing Advice Senior Appointment Hammond Baptist High School City Baptist High School Hyles-Anderson College Other Spiritual Growth Advice About Future Job/Unemployment Issues School Issues (HB, CB, HAC) Want to Know Preacher Better Other
Details
	What are your goals/objectives from this requested meeting? (In other words, what outcome would you like to see from this appointment?)
	In order for you to accomplish your desired outcome, goals, and objectives, what possible solutions or possible directions could you pursue in this situation? (Please list two or more.)
Marital Status	--Select-- Single Married
Are you a member of First Baptist Church of Hammond, Indiana?  --Select-- Yes No Name of Sunday School Teacher Pastor's Name Pastor's Phone Number Pastor's Church Church City/State/Country
When did you trust Christ as your Saviour?
Where did you trust Christ as your Saviour?
Age Category	--Select-- 50+ 19-49 High School Junior High Child
Are you currently a student?  --Select-- Yes No What school?
Address
City
Country	--Select-- USA Other Other Country   State   --State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip/Postal Code
E-mail
Phone	Include area code and/or country code (if necessary).
Security	Get another CAPTCHA Get audio CAPTCHA Get image CAPTCHA