Hello! We'd love to help.
Well done for taking this brave step towards freedom, restoration and renewal. We know that through a growing relationship with Jesus Christ people can find the help and freedom that they need. Sometimes though, we need someone to help us walk that journey out. We would love to help you!
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.
Cohabiting (living together but not married)
Which Urban Life Church do you attend?
I don't attend Urban Life Church but do attend another church
I don't attend any church
If you attend a Urban Life Small Group, please tell us which one?
What / who led you to this form?
Briefly describe the life-challenge that you are facing?
How long have you been facing this life-challenge?
Have you received help for this life-challenge previously? If so, please provide more details, e.g. counselling, church, psychologist?
Are you currently receiving help for this life-challenge? If yes, please specify where:
Have you received any previous professional diagnoses?
How would you describe your current physical health (exercise, food choices etc)?
What are your current and/or previous spiritual/religious beliefs or worldviews?
In the past 12 months, which of these, if any, are applicable to you?
Change of lifestyle habits
Changes in living or working conditions
Death of someone close to you
Difficulties in the workplace
Emotional or Physical Abuse
Fired / Retrenched
Injury or illness
Involvement in the occult
Psychological or medical diagnoses
Starting, stopping or completing studying
Victim of violent crime
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
Initials & Surname (Signature)
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Urban Life Church.