Application for a Debrief
Email address *
Name *
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Phone number
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Mailing Address
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Date of Birth (Month, Day, Year) *
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Nationality
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Status
Do you have Children?
Organization you are with *
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Location of your work
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Number of years working with this Organization?
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Are you raising support
Name of Overseer
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Overseer's email address
Your answer
Sending Church
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How long have you been affiliated with this Church?
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Name of Pastor or Overseer?
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Pastor or Overseer's phone number
Your answer
Church Pastor or Overseer's email
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Have you seen a counselor, psychologist or psychiatrist in the last 6 months?
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Are you currently taking medication
If you have any food allergies please list them below
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Do you have any other allergies? Please list below
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Please check from the following list the areas that you think might need to be addressed in your debrief?
Please give any additional comments as to why you would like to be debriefed
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Name of Person you would like to give you a reference. (A reference form will be sent to them. Please let them know you need this filled out quickly.)
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Phone number of your Reference
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Email of your Reference
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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.
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Any other comments or consideration you would want us to know!
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