1.)  Full Name:  (First             Middle                  Last)
     
2.) Date of Birth: (Month/Day/Year)
3.)  Address:

4.) Telephone Number:

5.) Marital Status:
Married Single Divorced Separated Widowed Dating Engaged Remarried
6.)  Do you have children?
Yes No
6a.)  If Yes, how many ?
7.)  What is your occupation?
7a.) Do you enjoy your job?
Yes No
7b.) If No, why not?

8.) Do you attend a church?
Yes No
8a.) If Yes, which church?

8b.) Are you a member there?
Yes No
8c.) Are you involved in activities other than Sunday worship?
Yes No
8d.) If Yes, which ones?  
Sunday School Nursery Choir Women's Fellowship Men's Fellowship Soup Kitchen Vacation Bible School Prayer Meeting Home Bible Study
Other(s):
9.) Do you believe God loves you just the way you are?
Yes No
9a.) Why do you feel this way?

10.) Do you believe God is able and wants to help you enjoy life? Yes No
11.) How would you describe yourself right now?  
Happy Nervous Very Busy Outgoing Anxious Cry a lot Angry Enthusiatic Sad Friendly Desperate Lonely  
Other:
12.) Whom are you able to trust?
Your Family Your Pastor Friends at LEO God Yourself Close Friends
13.) In your opinion, what is your biggest problem?
14.) How can we help you with your problem?  

15.) What else do we need to know in order to help you?


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Copyright © 1991 Latin Evangelical Outreach
Written by Naomi Mangione
 All rights reserved throughout the world.