Faith + Strategy Intake Form – Every Child Matters

Name

First

Last

you (Give your

Email

Phone Number

Age Range

Multiple Choice

Faith + purpose clarity
Discipline + consistency
Relationship / marriage restoration (including divorce support)
Grief / loss (dealing with death)
Stress, anxiety, or feeling overwhelmed
Court / conviction / re-entry support (non-clinical)
Life transition (job, school, moving, major change)
Other (please explain)

What is the main situation you want to change right now? (Give details. What’s happening, and what outcome do you want?)

Have you experienced thoughts of harming yourself or ending your life? Choices aren’t needed here — keep it as a paragraph, but add this description under it: If yes, please contact 988 (Suicide & Crisis Lifeline) or call 911 for immediate help. This coaching program is not emergency support.

Required Agreements

I understand this is coaching/mentorship and not therapy or clinical treatment.
I understand this is not crisis support. If I am in immediate danger, I will call 911.
I agree to be respectful and participate honestly during coaching.