Life Change Questionnaire
John 5:6 "Do you want to get well?"
Name *
Contact Information - Phone and/or Email *
Age *
Today's Date *
What are the main issues in your life that brought you here? *
How do you feel this program can help you? *
Do you struggle with continuous homelessness? If so, what typically causes your homelessness? *
Please list the kinds of influences you had growing up (parents, siblings, mentors, teachers, etc.) and impact those influences had on you. *
What would you say have been the most defining moments in your life? (Positive/Negative) *
Do you attend a church on a regular basis? *
If yes, what is the name of your church?
Do you have a mentor? *
If so, what is his/her name?
How did he/she become your mentor?
How often do you meet?
What is your mentor's contact info (phone, email, etc.)?
What areas do you see a need for spiritual growth in your life? *
What significant issues would you say you struggle with most? *
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