Marriage Mentoring Request Form

Name

This address will receive a confirmation email

Phone

Address

Faith Background

Are you a regular attender of LAVC?

Yes No

If yes, how long have you attended?

If no, are you attending another church? If so, please list.

Check the answer that best describes you:

Seeker / not yet a Christ Follower New Christian Committed Christian Agnostic Not sure what I believe

About You

Why do you want to be mentored?

What is your occupation?

What are your hobbies?

What are your "pet peeves"?

What are your strengths?

What are your weaknesses?

Marital Status

How long have you been married to your current spouse?

Have you been previously married? If so, how many times?

Remarried Couples

How long were you married?

Were you a Christian at that time? Yes No

Was your spouse a Christian at that time? Yes No

When was the divorce final?

What was the reason for the divorce?

Did you try to reconcile? Yes No

Who filed for divorce? Me Him/Her

Did you or your previous spouse commit adultery? Yes, I did Yes, he/she did Yes, we both did No

Children

If you currently have children, please list the names and ages of all of them.If you have children from multiple marriages, please indicate whether the child is from the wife's previous marriage or your previous marriage.

Payment

There's a $50 fee that will cover the cost of your material. Please ensure that ONE of the forms you fill out for this request has a payment submitted with it.

Marriage Mentoring Payment

Mentee Agreement

By selecting the "I agree" button below, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. By selecting "I agree" you consent to be legally bound by this agreement's terms and conditions.
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 state of our marriage throughout the mentoring sessions or any time thereafter. I will allow Dare to be Different and LAVC leaders to access our personal information. All data collected by Dare to be Different will only be used as a quality control measure and will not be shared at any time with other parties.

I Agree

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Expiration Date/CVC

Name on Card Card Billing Address

Marriage Mentoring Request Form

Description

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