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DivorceCare Registration Form

Name

Cell Phone

Address

City

Zip

Email

How did you hear about DivorceCare?

Where are you in the divorce process?
Considering / not yet filedIn divorce proceedingsDivorce is final

Divorce Date?

Children? Ages:

Are you in counseling?

What church do you attend?

Pastors Name:

Emergency Contact (Name & Phone):

Registration fee is $20.00 which covers the cost of the workbook. If that is a financial difficulty, please let the leader know.

I understand confidentiality is mandatory in my support group and that anything said in the group is to stay in the group. I understand DivorceCare is not counseling, but a peer support group led by volunteers. I also understand the volunteers and/ or leaders of this program have an obligation to report any disclosure of intent to harm oneself or others to the pastors at Trinity, my church or any other appropriate agency.

I Understand

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