Mosaic Life Care Intake
Welcome to the Mosaic Life Care Ministry at Mosaic Church. We are grateful you are welcoming us into your life at this time. It is never easy to ask for help so we admire the courage, faith, and humility this first step represents. It is our prayer that God will bless this step and use our time together to build hope and direction into your life.

Our goal in this care and counsel ministry is to connect people to the life-transforming power of Jesus Christ. We are confident that through the Scriptures and the power of His Spirit, God has given us everything we need for life and godliness (2 Peter 1:3-4). It is our joy to help real people with real problems, using the Bible.

Our vision is larger than a few one-on-one meetings with a team member. Rarely does lasting change happen in isolation. As a part of our care process, we will encourage you to be involved in the life of our church in a variety of ways as we walk together. Our approach to care focuses on helping you identify how your beliefs, values, and desires express themselves in your emotions, relationships, decision making, and identity (Prov. 4:23; Matt. 6:21; Luke 6:45).

Our commitment as a church is to offer care and counsel services to adults in need. As a church, we are committed to help others glorify God with their thoughts, words, and actions through the community of faith. This is made possible by the redemptive power of Jesus Christ, the conviction and guidance of the Holy Spirit, and the instruction of God’s Word. Your care will be biblical, pastoral counseling in which the Scriptures are held as the final authority in all matters.

The next step in the care process is to complete the intake form you are now reading. We have designed it to enable the care process to start smoothly and connect you with the resources that fit your needs. The care form is designed to (1) help us to get to know you in a holistic and efficient manner and (2) help you organize your thoughts about your care objectives.

We ask that you complete these forms carefully (it will likely take about 30 minutes) and submit them to Mosaic Life Care Ministry. We will review them carefully and follow up as soon as possible. Please indicate when you are available for appointments below. Please note: the narrower your availability the longer you may have to wait to receive care, and there may be fewer team members available to work with you.

Care sessions typically last 1 hour. Childcare is not provided. Please arrange to be on time to maximize your benefit from care. We understand that tardiness is sometimes unavoidable but we will endeavor to end on time so as not to inconvenience the person coming in after you.

We are grateful to be able to serve you and look forward to walking with you.

Full Name *
Your answer
Gender *
Age *
Your answer
Address *
Your answer
Date of Birth *
MM
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DD
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Phone Number *
Your answer
May we leave a message here? *
Secondary Phone Number
Your answer
May we leave a message here? *
Required
Email *
Your answer
Occupation/Employer *
Your answer
Marital Status *
Name of Spouse
Your answer
Spouse's Age
Your answer
List children's names, ages, and genders:
Your answer
How did you hear about Mosaic's Life Care Ministry? *
Church Name: *
Your answer
Are you a member? *
Number of years at current church: *
Your answer
Are you part of a community group/missional community or bible study? *
Leader's Name
Your answer
Name of the Group and when do you meet?
Your answer
Please list the names of two or three people you trust and who you walk closely with. *
Your answer
Please list any ministry involvement (past and present): *
Your answer
Have you received Jesus Christ as your personal savior? *
Have you been baptized? *
Date of Baptism: *
MM
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DD
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How would you define the gospel and what it means to be a Christian? *
Your answer
Please note any recent changes in your spiritual life. *
Your answer
Check all boxes that describe you now: *
Required
Problem Areas
Please indicate how each of the issues below is currently affecting you, on a scale of 0-3 (0=None, 1=Mild, 2=Moderate, 3=Severe)
Abuse, Physical *
None
Severe
Abuse, Verbal/Emotional *
None
Severe
Abuse, Sexual *
None
Severe
Abuse in Past *
None
Severe
Addiction *
None
Severe
Anger *
None
Severe
Anxiety *
None
Severe
Apathy *
None
Severe
Bad Memories *
None
Severe
Bitterness *
None
Severe
Caring for Parents *
None
Severe
Chronic Pain *
None
Severe
Codependency *
None
Severe
Communication Problems *
None
Severe
Conflict Resolution *
None
Severe
Compulsions *
None
Severe
Depression *
None
Severe
Fear *
None
Severe
Financial Issues *
None
Severe
Greed *
None
Severe
Grief *
None
Severe
Guilt *
None
Severe
Homosexuality *
None
Severe
Identity Struggles *
None
Severe
Impatience *
None
Severe
Infertility *
None
Severe
Insecurity *
None
Severe
In-Law Conflict *
None
Severe
Jealousy *
None
Severe
Judgmentalism *
None
Severe
Lifestyle Change *
None
Severe
Loneliness *
None
Severe
Lying *
None
Severe
People-Pleasing *
None
Severe
Perfectionism *
None
Severe
Pornography *
None
Severe
Pre-Marital Sex *
None
Severe
Pride *
None
Severe
Priorities *
None
Severe
Procrastination *
None
Severe
Lack of Purpose *
None
Severe
Rebellion *
None
Severe
Rejection *
None
Severe
Relationship Struggles *
None
Severe
Parental Struggles *
None
Severe
Marital Struggles *
None
Severe
Struggles with Self-Control *
None
Severe
Self-Injury *
None
Severe
Selfishness *
None
Severe
Shame *
None
Severe
Suicidal Thoughts *
None
Severe
Date of last physician's visit:
MM
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DD
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YYYY
Results:
Your answer
Please describe any current physical health issues or concerns: *
Your answer
Please describe the current problem, as you understand it. *
Your answer
How distressed are you? *
not at all distressed
extremely distressed
What has been most effective in helping with this problem? *
Your answer
What has been least effective in helping with this problem? *
Your answer
Other than counsel, what help are you seeking? *
Your answer
Please describe any family history (the family that you grew up in), which might be pertinent to the concerns that you bring to our conversations (your relationship with your parents, their relationship with each other, significant losses or events): *
Your answer
What are your expectations or concerns in coming to receive care and counsel? *
Your answer
Is there any other information we should know?
Your answer
I have read and agree to the above Life Care Ministry Agreement. *
Signing your full name indicates electronic signature.
Your answer
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