Women's Inquiry Form

First & Last Name
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Age:
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City/State:
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Safe Number (write none if it's not safe to contact via call or text)
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Safe Email (write none if it's not safe to contact you via email)
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Another contact method if email or phone are not safe options?
How did you hear about A Soul Made Well?
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A Family Member
A Friend
Abuse Recovery Ministry Services
Called to Peace Ministries
Church/Pastor Referral
Counselor's Referral
His Heart Foundation
Hope After Betrayal
Instagram Page
Living Waters of Hope
Online Search
Restored Nation
Other
What categories of abuse/control have you experienced?
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Coercion/Threats
Emotional
Financial
Intimidation
Isolation
Male privilege
Minimize/Deny/Blame
Pets/Property
Physical
Psychological
Sexual
Spiritual
Stalking
Using Children
Verbal
Other
If you are comfortable doing so, please share briefly about your abuse history.
Please list any children by gender and age (Ex: F-5, M-7)
Are you feeling safe (emotionally and/or physically) in your current living situation?
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Yes
No
Uncertain
Are you feeling safe (emotionally & physically) when OUTSIDE of your home?
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Yes
No
Uncertain
What is your current living situation? (EX: Still living with spouse, live with children only, live alone, etc)
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Are you currently going through any kind of litigation or court order regarding custody for your child/children?
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No
Yes
Pending
No, but I anticipate I will be in the future
Temporary Orders have been made
Final Orders have been made
N/A I have no children or no minor aged children
Do you feel supported by your church pastor/leaders? (In other words, they believe you and have your sense of safety as top priority).
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Yes
No
Uncertain
Please check all options you're available for counseling sessions: (Please take into account these are Pacific Standard Times)
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I am flexible and will take any timeslot.
Monday Afternoons (2:30 or 3:45)
Monday Evenings (5:15 or 7:15)
Wednesday Mornings (9:30 or 10:45)
Wednesday Afternoons (12:30 or 1:45)
Wednesday Evenings (6:00 or 7:15)
Thursday Afternoons (2:45 or 4:00)
Thursday Evenings (5:30 or 6:45)
Friday Mornings (9:00 or 10:15)
Friday Afternoons (12:00 or 1:15)
Please check your preferred method for meeting:
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In-Person Session
Video Session
Phone Session
I have flexibility to meet in-person or by video/phone
What are your counseling frequency goals to begin with? (NOTE: It is my preference that new clients commit to coming on an every other week basis at a minimum)
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1x per week
Every other week
1x per month
I'm not sure
Use this space to explain any additional comments/questions or provide me with any other information that might be helpful to know.
Please click on the checkbox to continue
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Domestic Abuse Counseling Inquiry

Thank you for your interest in domestic abuse counseling with A Soul Made Well Pastoral Counseling! Please fill out this form and I will be in touch shortly. Blessings!