My Vineyard Columbus - Apply for Life Support Mentoring

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Application to Receive Life Support Mentoring

Request for Life Support Mentoring

The Support for Life Ministry has a trained team of Life Support Mentors who come alongside people in difficult seasons or situations to minister insight, healing, and spiritual growth in a one-on-one, non-clinical environment. Life Support Mentors meet with individuals on a short term basis (8-10 sessions over a 3 month maximum time frame) and are trained to provide a listening ear, supportive encouragement, empowered prayer, and biblical guidance.

Our mentors are trained, competent volunteers—but please remember this is not professional counseling. Also, due to demand, please be aware that we sometimes have a wait-list, and priority is given to Vineyard Columbus members. You will be contacted if you have to be placed on the wait-list.

If you're a member or regular attender and would like to meet with a Mentor, please fill out the following application.

Statement of Understanding

I understand that Life Support Mentoring is not professional counseling and is limited to 8-10 sessions within a three month window.

Consent of Understanding is Required

Personal Information

First Name *

First Name * is Required

Last Name *

Last Name * is Required

Cell Phone

Do you wish to receive periodic text messages from Vineyard Columbus?
With a cell phone listed and the "Allow Texts?" check box checked, you agree to allow Vineyard Columbus to send you texts.

Text: HELP for help, or STOP to cancel to 98977.
Message and data rates may apply. Message frequency varies.
Vineyard Columbus Terms of Service and Privacy Policy

Allow Texting

Email *

Email * is Required

Birth Date

Birth Date is RequiredInvalid Date

Gender

Gender is Required

Address

Street Address is required

City is required

State is required

Zip Code is required

Marital Status

Marital Status is Required

Employer

Employer is Required

Occupation

Occupation is Required

Involvement Information

Have your or your spouse (if married) been previously married?

YesNoHave your or your spouse (if married) been previously married? is Required

Please explain:

Please explain: is Required

Children? (names and ages)

How did you hear about Life Support Mentoring?

How did you hear about Life Support Mentoring? is Required

Do you attend Vineyard Columbus?

YesNo

If Yes, which campus?

If Yes, which campus? is Required

Are you a Member of Vineyard Columbus?

YesNoAre you a Member of Vineyard Columbus? is Required

Are you active in a Small Group?

YesNoAre you active in a Small Group? is Required

Do you currently serve in a ministry at VC?

YesNoDo you currently serve in a ministry at VC? is Required

Where do you serve?

Where do you serve? is Required

Would you prefer a Spanish speaking counselor?

YesNoWould you prefer a Spanish speaking counselor? is Required

Would you describe yourself as a Christian?

YesNoWould you describe yourself as a Christian? is Required

Please describe your testimony of coming to Christ

Briefly describe your health

Briefly describe your health is Required

List any significant illness or injury.

List any significant illness or injury. is Required

What is the primary reason for seeking Mentoring?

What is the primary reason for seeking Mentoring? is Required

What other steps have you taken regarding this issue?

What other steps have you taken regarding this issue? is Required

List any current medications that you're taking:

List any current medications that you're taking: is Required

Have you ever seen a psychiatrist, psychologist, or mental health professional?

YesNoHave you ever seen a psychiatrist, psychologist, or mental health professional? is Required

If Yes, please explain the reason.

If Yes, please explain the reason. is Required

Are you currently seeing a psychiatrist, psychologist, or mental health professional?

YesNoAre you currently seeing a psychiatrist, psychologist, or mental health professional? is Required

If Yes, please explain the reason.

If Yes, please explain the reason. is Required

What are your expectations for Support for Life Ministry and the time with a Mentor?

What are your expectations for Support for Life Ministry and the time with a Mentor? is Required

Please share any additional information that we should know:

Indicate Your Current Levels of Concern

Indicate the level of concern for the following issues. (0=No Concern, 5=Serious Concern)

Alcohol Use

012345Alcohol Use is Required

Anger

012345Anger is Required

Authority Conflict

012345Authority Conflict is Required

Relationship Problems

012345Relationship Problems is Required

Depression

012345Depression is Required

Drug Use

012345Drug Use is Required

Family

012345Family is Required

Fear

012345Fear is Required

Financial

012345Financial is Required

Forgiveness

012345Forgiveness is Required

Gambling

012345Gambling is Required

Grief

012345Grief is Required

Homicidal Thoughts

012345Homicidal Thoughts is Required

Inferiority Feelings

012345Inferiority Feelings is Required

Irritability

012345Irritability is Required

Legal Issues

012345Legal Issues is Required

Loneliness

012345Loneliness is Required

Marriage Problems

012345Marriage Problems is Required

Parenting

012345Parenting is Required

Physical Health

012345Physical Health is Required

Poor Self Discipline

012345Poor Self Discipline is Required

Poor Social Relationships

012345Poor Social Relationships is Required

Pornography

012345Pornography is Required

Self-Injury Behavior

012345Self-Injury Behavior is Required

Sexual Abuse

012345Sexual Abuse is Required

Sexual Issues

012345Sexual Issues is Required

Sleep Troubles

012345Sleep Troubles is Required

Spiritual Life

012345Spiritual Life is Required

Strange Thoughts

012345Strange Thoughts is Required

Stress

012345Stress is Required

Suicidal Thoughts

012345Suicidal Thoughts is Required

Indicate any other area not listed

For this other area, please list the level of concern:

012345

Please indicate 3-4 consistent times you have availability to meet with a mentor:

Please indicate 3-4 consistent times you have availability to meet with a mentor: is Required

Electronic Signature

By typing your name in the box provided you are indicating that the information provided is accurate and true.

Signature

Signature is Required

Signature Date

Signature Date is Required

Edit Registrant Form

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