Marriage Mentoring Request Form

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Marriage Mentoring Request Form
Please return this form to Allison Park Church (along with the mentoring fee)
Date: _____/_____/_________
Name: __________________________________________________ Age: ____________
Address: _____________________________________________________________________________________
City: ______________________ State: ________
Zip: _____________
Cell Phone: __________________ Other Phone: __________________ Ethnic Origin: _____________________
E-mail Address: ____________________________ Occupation: _________________________________________
Member
Regular Attendee at Allison Park Church? q YES, How long? ______________ q NO
/
• If not, are you attending another church? q YES, Church Name_____________________________ q NO
Check the answer below that best describes you:
qSeeker/not yet a Christ follower
qNew Christian
qCommitted Christian
qAgnostic/Atheist
qI’m not sure what I believe
More About You!
Hobbies: ______________________________________________________________________________________
Pet Peeves: ___________________________________________________________________________________
Strengths: _____________________________________________________________________________________
Weaknesses: __________________________________________________________________________________
Do you suffer from depression or anxiety?  YES
 NO
• If yes, are you under a doctor’s care or currently taking medication? ________________________________
Marital Information:
Length of time dating prior to wedding? ____________________________________________________________
Please list your Wedding Date:
_________________________________________________________________
Have you been previously married? q YES
q NO
• How many times? _______
• How long were you married? ___________________
• What was the reason for the divorce? _______________________________________________________
What qualities do you admire about your partner?
_______________________________________________
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