Orland Evangelical Free Church | Problem Worksheet

Office use:  File #____________

BASIC INFORMATION ABOUT THE PROBLEM

DATE:___________________

PERSONAL INFORMATION

NAME: ___________________________________

PHONE #:________________ CELL#: __________________

Contact Preference and Best Time to Contact?___________________________________________________________

Can we leave a message?   YES   NO

THE BASIC PROBLEM AS YOU UNDERSTAND IT:

Briefly complete the following (please use the back if necessary):

1. PLEASE DESCRIBE YOUR PRIMARY CONCERN(S).

2. WHAT HAVE YOU DONE ABOUT IT/THEM?

3. WHAT DO YOU SEE AS SUCCESS IN THIS CASE?  IN OTHER WORDS, WHAT IS AN IDEAL OUTCOME?

4. WHAT PROMPTED YOU TO SEEK HELP NOW?