Divorce Inquiry Form

First and Last Name:
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Age
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City/State:
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Phone Number:
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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
Hope After Betrayal
Instagram Page
Living Waters of Hope
Online Search
Restored Nation
Other
Where are you at in the divorce process?
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Nothing has been filed yet
1-3 months
4-6 months
6-12 months
1-2 years
2+ years
Divorce has already been finalized
Other
If applicable, date of separation:
If already divorced, date it was finalized?
Some specific things going on that have led to divorce or possibility of divorce: (Check all that apply)
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Abandonment
Addiction
Betrayal
Covert Control
Domestic Abuse
Emotionally Destructive Marriage
Other (please share below)
If you selected "Other" please briefly describe what that is referring to below:
Are you feeling emotionally safe in your current living situation?
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Yes
No
Uncertain
Are you feeling physically safe in your current living situation?
Yes
No
Uncertain
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
Child custody orders have already been made
Do you feel supported by your church pastor/leaders in your current circumstances?
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Yes
No
Uncertain
Check all options you're available for counseling: (these are Pacific Standard Times)
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I am flexible and will take any timeslot you can fit me into your schedule.
Monday Afternoons (1:15, 2:30, or 3:45)
Monday Evenings (5:15)
Wednesday Mornings (9:30 or 10:45)
Wednesday Afternoons (12:30 or 1:45)
Wednesday Evenings (5:15)
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)
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
Check your preferred method for meeting:
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In-Person
By Phone
By Video
I am flexible and can meet in-person or by phone/video
Use this space to add additional comments/questions or provide any other information that might be helpful to know.
Please click on the checkbox to continue
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Divorce Counseling Inquiry

Thank you for your interest in divorce counseling with A Soul Made Well Pastoral Counseling! Please ONLY fill out this form if you are a woman facing separation/divorce as a result of your spouse's abandonment, addiction, abuse, or affairs. I will be in touch shortly. Blessings!