Marriage Intake Form - The Worship Center

Phone number *

Gender *

How old are you? *

Spouse Name *

First and Last Name

Primary campus *

Have you ever attended one of the IM Conferences? *

Have you ever attended one of our Group Marriage Intensives? *

Is your spouse willing to meet for counseling? *

In your current relationship, have you ever been separated? *

What is your current marital status? *

How many years have you been married? *

Please list any children you have, if applicable. *

(Name / Age / Sex / If Blended)

What is the biggest problem you're facing in your relationship? *

What are your expectations and hopes from receiving ministry? *

Tell us more about you.

Please describe your spiritual life journey below. *

How long have you attended TWC? *

How often do you attend the Sunday Services TWC? *

Do you currently attend any of the TWC Community Groups? *

Please select any of the following that you've struggled with in the past. *

No judgement here, we've struggled too!

Alcohol Abuse

Pornography

Chemical Abuse

Chronic Gambling

Adultery

None

Other

Please select any of the following that you're currently struggling with. *

No judgement here, we've struggled too!

Alcohol Abuse

Pornography

Chemical Abuse

Chronic Gambling

Adultery

None

Other

Please select any issue(s) you've struggled with in the past. *

In order for your marriage to be healed and whole, you have to be healed and whole. We won't disclose this information to anyone, but want to help you get free from anything that may be tormenting you and thus harming your marriage. Please be as honest as possible because we just want to help.

Worry

Suicide

Rejection

Unforgiveness

Anger

Family History of Mental Illness

Guilt / Shame

Eating Disorder

Low Self-Esteem

Night Terrors

Insecurity

Compulsive Thoughts

Obsessive Thoughts

Lustful Thoughts

Doubt

Depression

Anxiety

Fear

Physical Abuse

Sexual Abuse

Emotional Abuse

Other

Please select any issue(s) you're currently struggling with. *

In order for your marriage to be healed and whole, you have to be healed and whole. We won't disclose this information to anyone, but want to help you get free from anything that may be tormenting you and thus harming your marriage. Please be as honest as possible because we just want to help.

Worry

Suicide

Rejection

Unforgiveness

Anger

Family History of Mental Illness

Guilt / Shame

Eating Disorder

Low Self-Esteem

Night Terrors

Insecurity

Compulsive Thoughts

Obsessive Thoughts

Lustful Thoughts

Doubt

Depression

Anxiety

Fear

Physical Abuse

Sexual Abuse

Emotional Abuse

Other

How do you want to be contacted? *

Members Record of Disclosures
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and
disclosure of their protected health information (PHI). The individual is also provided the right to
request confidential communications or that a communication of PHI is made by alternative means,
such as sending correspondence to the individual’s office instead of the individual’s house.

By checking this box, you're agreeing to the marriage ministry guidelines listed out below. *

Marriage Ministry Guidelines

Consideration for being permitted to participate in voluntary pastoral ministry, herein referred to as “Ministry”, and prayer ministry, herein referred to as “Prayer Ministry”, the undersigned, herein referred to as “Ministry Recipient”, agrees as follows:

1. This is a church-based ministry of TWC providing Ministry and Prayer Ministry in individual and group settings. Our Ministry is done by pastoral staff and lay-ministers, herein referred to as “Ministers.” These individuals are not licensed as professional counselors, social workers, or psychologists because they perform spiritual & Biblical ministry and not secular or psychological counseling. If it becomes apparent that secular or psychological counseling may better address the Member’s needs, the Minister will immediately initiate an outside referral to a licensed professional counselor, social worker or psychologist.

2. Under all circumstances, sexual contact between a Minister and Ministry Recipient is prohibited. If any Minister suggests or attempts sexual advances, the Ministry Recipient shall terminate the session immediately and report the incident to the Executive Senior Pastor, or any other Elder not involved in the Minister.

3. Under normal circumstances, your Minister will use their good faith efforts to keep your discussions in confidence. However, you should be aware there are some situations in which your Minster may be required by law to report information to the proper authorities without your permission or knowledge. These situations include, but may not be limited to: a Counselee’s intent of harm to self or others, involvement in a felony, suicidal intentions, and/or reasonable evidence of child, disabled or elder abuse or neglect. Your Minister may also disclose information in response to a subpoena and/or court order issued by a court of law. Additionally, if you occupy a leadership or ministry position, your Minister may also disclose information to the person in authority over you, in the event he or she deems it relevant to your fitness or ability to fulfill your position.

4. Officially recognized church staff and lay-personnel may also have limited access to your pastoral file. Any other person seeking access to your pastoral file may do so only with your written permission. However, TWC cannot guarantee complete confidentiality regarding the information received from you.

5. TWC requires that parent(s) must be actively involved in any Ministry and/or Prayer Ministry that is extended to a minor child as determined by the Minister. At the discretion of the Minister, parent(s) will be required to make themselves accountable for active participation in Ministry and/or Prayer Ministry offered by TWC.

6. Ministry Recipients with any concerns or questions about this agreement agree to raise them with their Minster at the earliest possible time.

7. This agreement herein referred to as the “Ministry Agreement”, will govern all relations involved during the term of the ministry process. Should the Counselee participate in Prayer Ministry, the Voluntary Release, Assumption of Risk and Indemnity Agreement will be incorporated as part of this Ministry Agreement. It is agreed that any disputed or modifications of this Ministry Agreement will be determined directly between the individuals involved. If this Ministry Agreement is not satisfactory, then it is further agreed that disputes and disagreements will be taken to The Worship Center Board of Elders for mediation. In the event that a satisfactory resolution is not achieved, then it is further agreed that a mutually acceptable third-party mediator will be utilized. If the mediation is unsuccessful, then the dispute shall be submitted to Christian Arbitration under the Rules of Arbitration published by the Institute for Christian Mediation, www.HisPeace.org. All expenses incurred will be the responsibility of the party bringing the dispute.

I have read the above ministry agreement, understand it, and agree to the terms herein written. Voluntary Release, Assumption of Risk and Indemnity Agreement In consideration for being permitted to participate in voluntary prayer ministry, herein referred to as the “Prayer Ministry,” the undersigned. Release, waiver, discharge and covenant not to sue. Releasor and releasor’s personal representatives, assigns, insurer, heirs, executors, administrators, spouse and next of kin, hereby releases, waives, discharges and covenants not to sue The Worship Center of Lubbock, Texas and its directors, officers, elders, pastors, deacons, ministry team members, employees, agents and volunteers, as well as its successors, affiliates, and subsidiaries, all herein referred to as the “Releasees,” from any and all liability to Releasor, and to Releasor’s personal representatives, assigns, insurers, heirs, executors, administrators, spouses and next of kin for any and all loss, damage, or cost on account of injury to the person or property or resulting in the death of Releasor, whether caused by the negligence of Releasees or otherwise while Releasor is participating in the Prayer Ministry and any other activities in connection with the Prayer Ministry. Assumption of Risk. Releasor understands, is aware of, and assumes all risks inherent in participating in the prayer ministry. These risks include, but are not limited to, physical and emotional responses and reactions as a result of this Prayer Ministry. Indemnity. Releasor agrees to indemnify Releasees from any liability, loss, damage or cost Releasees may incur due to the participation by Releasor in the prayer ministry whether caused by the negligence of Releasees or otherwise. Releasor assumes full responsibility for and risk of bodily injury, death or property damage due to negligence of Releasees or otherwise while participating in the Prayer Ministry. Releasor expressly agrees that this Voluntary Release, Assumption of Risk and Indemnity Agreement, herein referred to as “Agreement,” is intended to be as broad and inclusive as permitted by the laws of the State of Texas and that, if any portion of this Agreement is held invalid, it is agreed that a balance, notwithstanding, continue in full legal force and effect. This Agreement, along with the Ministry Agreement contains the entire agreement between the parties regarding the Prayer Ministry.

Releasor represents that: I have carefully read this agreement. I understand, and it is a release of all claims, including the negligence of Releases. I have been given an opportunity to review this agreement with an attorney of my choosing. I understand that I assume all risks inherent in the Prayer Ministry set forth in this Agreement. I understand that I am indemnifying the Releasees.

The Worship Center 12701 Indiana Ave Lubbock, TX 79423 806.785.3609