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