Marriage Mentoring Request Form Page 2
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1
2Which of the following negatively affects your
?
Alcohol
Pornography
None
Other Substances
Infidelity
What is the hardest thing you ve had to deal with in your
and how did you deal with it? ____________
____________________________________________________________________________________________
____________________________________________________________________________________________
How do you deal with conflict in
_____________________________________________________
____________________________________________________________________________________________
What, if any, types of resources (ie: counseling, books, conferences) have you utilized to strengthen your
?
_____________________________________________________________________________________
Why do you want to be mentored? _________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Is there anything special we should know about you to better meet your needs? ______________________________
______________________________________________________________________________________________
Children
YES
NO If yes, please list children & answer the following question:
Name
Age ____ Parents: q Both q Mom only q Dad only
Name
Age _____ Parents: q Both q Mom only q Dad only
Name
Age _____ Parents: q Both q Mom only q Dad only
Name
Age _____ Parents: q Both q Mom only q Dad only
Name
Age _____ Parents: q Both q Mom only q Dad only
What effect has having children had on
?________________________________________________
_____________________________________________________________________________________________
M
A
ENTEE
GREEMENT
I, ________________________, understand that the Mentor Couple we meet with are not professional counselors,
but volunteer marriage mentors who agree to share their life experiences with us in an effort to help us strengthen
our marriage. I understand that we are responsible for the success of our own marriage and I do not hold our
Mentor Couple responsible for the state of our marriage throughout the mentoring sessions or any time thereafter. I
understand that all information shared in this application and during the marriage mentoring sessions will be kept
confidential between the Allison Park Church Marriage Mentors and the Allison Park Church Pastors.
Please sign here: ___________________________________________ Date: _____/_____/_________
We are paying the one-time mentoring fee: q With Enclosed Check q Online (with Credit Card)
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