Start Your Journey

Name(Required)

First Last

Age

Address

City State / Province / Region

Phone(Required)

Email(Required)

Marital Status(Required)

Marital Status

Single

Married

Divorced

Widowed

How long have you been married?(Required)

How long?

How long have you been divorced?(Required)

How long?

How long have you been widowed?(Required)

How long?

Do you have any children?(Required)

Children?

Yes

Number of Boys

Number of Girls

Are they all living?

Yes

Explain if any of your children are not living.

What has been going on that made you want to seek help?(Required)

What will the ideal outcome be for you?(Required)

Are you, or the person you are seeking help for, now or have you ever been associated with a church or religious organization?(Required)

Are you, or the person you are seeking help for, now or have you ever been associated with a church or religious organization?

Yes

Not considering your current situation, at first thought, where do you feel you are spiritually, on a scale of 1-5 with being the strongest.(Required)

Not considering your current situation, at first thought, where do you feel you are spiritually, on a scale of 1-5 with being the strongest.

1=weak	2=don't know	3=fair	4=good	5=strong

Did you grow up attending church?

Yes

Which denomination was the church you grew up in? If several list them all from earliest to latest.(Required)

In a written format, how do you describe your spiritual upbringing?(Required)

In a written format, how do you describe your spiritual upbringing?

Member of AOY(Required)

Do you attend or fellowship with the Assembly of Yahuah?

Yes

Length of time with AOY(Required)

How long have you been with the Assembly of Yahuah?

What comes to mind when you think of Soul Care?

Are you, or the person you are seeking help for, currently seeing a psychiatrist, psychologist, social-worker, or counselor? (Check all that apply.)(Required)

Are you, or the person you are seeking help for, currently seeing a psychiatrist, psychologist, social-worker, or counselor? (Check all that apply.)

Psychiatrist

Psychologist

Social-worker

Counselor

None of the above

Have you, or the person you are seeking help for, ever receive a mental health diagnosis?(Required)

Have you, or the person you are seeking help for, ever receive a mental health diagnosis?

Yes

If you are currently under care, explain that as well.

Are you, or the person you are seeking help for, currently taking any medications?(Required)

Are you, or the person you are seeking help for, currently taking any medications?

Yes

If yes, please list the medication(s) you are taking.

How do you prefer to be contacted?(Required)

How do you prefer to be contacted?

Phone Call

Text

How did you find out about Compassionate Soul Care Ministry?(Required)

How did you find out about Compassionate Soul Care Ministry?

Google Search

Social Media

Assembly of Yahuah

Word of Mouth

Other

Name of Person who Referred you(Required)

Name of Person who Referred you

Share details of how you found out about Compassionate Soul Care Ministry(Required)

Share details of how you found out about Compassionate Soul Care Ministry

What exactly on Social Media did you see, and was it Facebook, YouTube, or another platform?(Required)

What exactly on Social Media did you see, and was it Facebook, YouTube, or another platform?

What did you search for on Google?(Required)

What did you search for on Google?

MY CONFIDENTIALITY STATEMENT TO YOU

I, Diane Foster, owner of Compassionate Soul Care Ministry (CSCM) upholds the following statement:

Understanding that you will be providing CSCM with confidential information, CSCM agrees to never share this information with any friend or family member without your approval. CSCM will only share your information with other agencies such as a social service agency, mental health agency, or court of law when mandated (ordered) to do so. Unless required by law CSCM will not disclose your information to anyone, including friends, family members, or religious organizations.

Diane Foster, Founder, Compassionate Soul Care Ministry (CSCM)

DATED: September 23, 2023

Do you understand & agree with the confidentiality statement above?(Required)

Do you understand & agree with the confidentiality statement above?

Yes

I, Diane Foster, owner of Compassionate Soul Care Ministry (CSCM) upholds the following statement:

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