Request for Spiritual Care

Name / Age
Spouse / Spouse’s Age
Address / 1stPhone
City / State / Zip / 2ndPhone
Email / Do you attend CrossroadsChurch and Ministries [CCM]?Yes No / How Long?
Are you married? Yes No
If yes, how long have you been married: / Number of times you’ve been married:
Number of children / Ages

Who referred you to CrossroadsCareCenter?

Applicant For which area(s) are you requesting spiritual guidance? Spouse

AddictionMarriage Addiction Marriage

DivorceParentingDivorceParenting

Doctrinal QuestionsPre-Marital Doctrinal QuestionsPre-Marital

Family IssuesSpiritual GrowthFamily IssuesSpiritual Growth

FinanceGriefFinanceGrief

Women’s/Men’s IssuesHealingWomen’s/Men’s IssuesHealing

Please relate briefly the matter for which you are requesting spiritual guidance:

PLEASE ANSWER THESE QUESTIONS:

Applicant Spouse

Yes No Have you asked Jesus Christ to be the Lord and Savior of your life? Yes No

Yes No Are you a partner at CCM?Yes No

Yes NoHave you completed any of the Crossroads Core Classes? Yes No

If yes, please indicate which ones:

101 Experience Crossroads 101 Experience Crossroads

201 Experience God 201 Experience God

301 Experience Ministry 301 Experience Ministry

401 Experience Leadership401 Experience Leadership

Yes No Do you attend a Small Group? Yes No

Which one?

Yes No Has anyone at CCM ever offered spiritual guidance to you? Yes No

Who?

Yes No Is anyone at CCM currently offering spiritual guidance to you? Yes No

Who?

Yes No Have you ever sought outside counseling for this particular issue? Yes No

Yes No Are you currently in outside counseling? Yes No

Where?

STATEMENT OF UNDERSTANDING

Each person requesting spiritual care (i.e. biblical guidance or input) should read carefully and initial each point in the following Statement of Understanding. If seeking spiritual guidance as a married couple, it is necessary that each spouse read carefully and initial each of the points below.

Initials Spouse Initials

1. The Member/Attendee seeks and requests of his/her own free will to receive spiritual care from CCM.

2. The Member/Attendee understands that CCM offers spiritual care. Those desiring legal or medical care are recommended to seek such assistance through appropriate channels outside of CCM. The Care Ministers, Mentors, Coaches and Pastoral staff provide life direction based on Biblical wisdom and are not Therapists, Psycholoist or Psychiatrists. This is a service spiritual in nature and is free of charge and provided by trained

staff and volunteers. CCM care center does have liscensed Counselors/Therapists who serve on the Care team for an hourly fee. From this application a recommendation for spiritual care, in- house counseling or outside psychological care will be made.

2. The Member/Attendee understands that spiritual care is being provided byCCM at no cost by a licensed or ordained minister OR a layperson designated by the staff to offer spiritual care.

3. The Member/Attendee understands that all records pertaining to the offering of spiritual care are the exclusive property of CCM, not of the Member/Attendee.

4. All communications involved in the offering of spiritual care are treated as confidential. However, it is to be understood that certain exceptions could occur, such as:

a. When required under Michigan law, including but not limited to, the disclosure of physical or sexual abuse under applicable reporting statutes.

b. Under lawful order or subpoena of any civil or criminal court with proper jurisdiction.

c. In case of threats of suicide and/or homicide when the minister determines there is a seriousthreat to the life of the one seeking spiritual guidance or a third party.

6. In order to receive spiritual care at CCM, all associated or involved parties freely and voluntarily agree to release forever CCM, its ministers, staff, directors, spiritual care providers, officers, board members and other representatives from any and all liability, claims, losses or damages. This statement of understanding acts as a release and is binding on my heirs, assigns or successors in interest in my capacity.

7. The offering of spiritual care may be terminated at any time by the mutual consent of both partiesor at the request of either party.

Signature / Date
Signature of spouse (if participating) / Date
Mail or deliver this completed form to:
Crossroads Church & Ministries
Attention: Pastoral Care Dept.
717 US Highway 27
Marshall, MI 49068 / Or Email this completed form to: