A Step Toward Freedom
Well done on taking this step on a journey that we believe can lead to restoration, renewal and freedom through a growing relationship with Jesus Christ.

We understand that your information is sensitive, and we promise to keep it confidential, in accordance with the POPI Act. Information will only be shared with members of the Care Team at Urban Life Church, in order to facilitate appropriate care for you.

When completing this form, please be as detailed as possible to help us facilitate this process and care for you in the best way we can.

A member of the Care Team will get back to you within 72 hours to suggest the next step in this journey.
Name *
Your answer
Mobile number *
Your answer
Your answer
Suburb *
Your answer
Your answer
Marital Status *
Gender *
Which Urban Life Church do you attend? *
If you attend a Urban Life Small Group, please tell us which one?
Your answer
What / who led you to this form?
Your answer
Briefly describe the life-challenge that you are facing? *
Your answer
How long have you been facing this life-challenge? *
Your answer
Have you received help for this life-challenge previously? If so, please provide more details, e.g. counselling, church, psychologist? *
Your answer
Are you currently receiving help for this life-challenge? If yes, please specify where:
Your answer
Have you received any previous professional diagnoses?
Your answer
How would you describe your current physical health (exercise, food choices etc)? *
Your answer
What are your current and/or previous spiritual/religious beliefs or worldviews? *
Your answer
In the past 12 months, which of these, if any, are applicable to you?
A Care Team leader will review your form and we will get back to you within 72 hours. We are not a counselling center but we aim to facilitate life change and finding freedom through and in Jesus Christ. Your information will be kept confidential and will only be shared with members of the Care Team, although if the Care Team Leader feels that I am at risk of self-harm, or harm to others, they have a duty to inform others.
I acknowledge that Care Ministry sessions are not professional counselling sessions and that none of the team members are licensed counselors.

I understand that these team leaders are, to the best of their ability, doing what they can to help me achieve more freedom in my life.

The Care Ministry model is based on biblical solutions that facilitate life change through a growing relationship with Jesus Christ. All emotional and behavioral changes are a natural result of a clear understanding of your identity in Christ, and living the way God intended.

I understand that Urban Life Church is a non-profit organization that does not charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the team members of this ministry.

The information, as needed, may be shared with the leaders of the ministry team only, so as to further your total healing process. This may include future meetings with spiritual mentors in the church to set appropriate boundaries for your personal and spiritual growth. I understand that Urban Life Church is obligated to report abuse toward children and elderly to the proper authorities.

I understand that if any member of the Care Team feels that I am at risk of self-harm, or harm to others, they have a duty to inform others.

I agree to hold Urban Life Church and its team members free from any and all liability, loss or damage of any kind that may arise as a result of assistance, which I have received, or from my involvement with Urban Life Church.

I have read this disclaimer and release of liability and understand and agree with it at my own free will.I agree to the above terms and conditions
Date *
Initials & Surname (Signature) *
Your answer
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