Application

Please complete and submit the following information.

Name

Address

Home Phone

Work Phone

Cell Phone

Signed

Date

Please answer the following questions as completely and accurately as possible

Are you currently seeing a professional therapist on a regular basis? How long? How frequently? Please indicate if current counseling is with a pastor, lay counselor, group, or anyone other than a professional therapist.

What is prompting you to attend Reclaim?

Overall, what do you hope to receive as a result of your participation in Reclaim?

Is there anything else you would like us to know/be aware of in considering your attendance?

2 + 3 = ?