Application for a Debriefing

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Email *

Name: *

Phone number: *

Mailing Address:

Date of Birth (Month, Day, Year): *

Nationality: *

Marital Status: *

Single

Married

Divorced

Widowed

Do you have Children? *

Yes

Name of your Organization: *

Location of your work: *

Number of years working with this Organization: *

Do you raise your own financial support? *

Yes

Name of Organizational Overseer: *

Overseer's email address: *

Sending Church: *

How long have you been affiliated with this Church?

Name of Pastor:

Pastor's phone number and email address:

Have you seen a counselor or psychiatrist in the last 6 months? If yes, please explain. *

Do you have any food allergies? Please list them below. *

Do you have any pet allergies? If yes, how severe is your allergy? (Or other environmental allergies) *

Please check the areas where you feel the greatest need for debriefing: *

Stress

Loss

Transition

Grief

Injustice

Other:

Required

Please give any additional comments as to why you would like to be debriefed:

Name of Leader/Overseer/Mentor you would like to have fill out a reference for you. (A reference form will be sent to them. Please let them know you need this filled out quickly.) *

Phone number of your Reference: *

Email of your Reference: *

Please state at least three options for when you would like to be debriefed. Please note we often are booked out 6 months in advance. *

Is there anything else you would like us to know as we consider your application for debriefing?

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