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Advocate Form

Which retreat is right for me?

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Please fill out this form, being as specific as you can in accordance with the questions. Filling out this form should take you no more than 20-30 minutes. We look forward to meeting and caring for you!

What is today's date?*

Name*

First Last

Your age*

If you are under 21 y.o. please complete the form for minors: https://twelvestones.org/counseling-application-for-minors/

Your gender*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Best Contact Number*

Occupation*

Total Household Annual Income*

Marital Status*

I'm filling this form out for*

How did you hear about us?*

If by referral, please provide their name and email address.

Spouse's Information

If applicable.

Spouse's name*

First Last

Spouse's contact number*

Spouse's Email*

Date of marriage*

Have you ever been separated? If so when and how long?*

Have either of you filed for divorce?*

When was the divorce filed?*

How did you hear about us (name of person, website, or conference)?*

Name of church (Insert N/A if you do not attend)*

Pastor's name*

Pastor's email

Describe your participation in the local church.*

(i.e. "I serve as an usher.", "I lead a small group.", "I attend a small group.", etc.)

Do you have any health issues that would influence your ability to receive counseling?*

Yes

No

Counseling Information

By filling out these fields, you are granting us permission to send a brief form to your current counselor to provide us with information related to your case.

Have you ever received counseling before?*

Yes

No

What were the key observations and take-aways from that experience?*

Are you currently in counseling?*

Yes

No

Counselor's Name*

First Last

Counselor's Email*

By checking this box, I grant Twelve Stones Ministries permission to contact my current counselor and obtain any applicable information related to my situation.*

Yes, I agree.

What would you say is/are the problem(s) that bring you to Twelve Stones?*

Do you have any fears and/or concerns regarding your time at TS?*

What concern(s) do you want to make sure we address in our time together?*

Advocate Information

Your next steps involves bringing in an advocate(s) to walk alongside of you during this time. An advocate is someone who loves God, loves God's Word, someone who loves & cares about you and would be willing and able to attend the counseling sessions with you.

Advocate's Name*

First Last

Advocate's Phone Number*

Advocate's Email*

IMPORTANT INFORMATION - READ CAREFULLY*

I have read the following information.

OUR GOAL
Our goal in providing Christ-centered counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to enjoy fully His love for you and His plans for your life.

BIBLICAL BASIS
We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than on those of secular psychology or psychiatry. Although some of the pastoral or lay counselors of Twelve Stones may be licensed in other fields, such as medicine or psychology, they will not practice in that capacity but as biblical counselors under the authority of the board of directors that serve Twelve Stones Ministries.

NOT PROFESSIONAL ADVICE
If you have significant legal, financial, medical or other technical questions, you should seek advice from independent professionals in those fields. Our ministry staff and lay counselors will be happy to cooperate with such advisers and help you to consider their counsel in the light of relevant scriptural principles.

CONFIDENTIALITY
We believe confidentiality is an important aspect of the counseling process. Therefore, we will carefully guard the information you entrust to us.

There are four situations, however, when it may be necessary for us to share certain information with others:

1. In discussions with the pastor of your local church, physician, previous counselor and/or your advocate for the sole purpose of gaining information for your care or to help in follow up and after care.
2. When a counselor is uncertain of how to address a particular problem and needs to seek advice and wisdom from another Twelve Stones staff member. We will make every effort to be sensitive to your situation.
3. When there is a clear indication that someone may be harmed unless others intervene.
4. When a person persistently refuses to renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (see Proverbs 15:22; 24:11, Matthew 18:15-20).

COMMUNICATION AND COMMUNITY
It is the mission and vision of Twelve Stones to help local church more faithfully care for those in their flock who are hurting. It is imperative to our mission and your long-term care that we stay in consistent and regular communication with the pastoral leadership of your local church and/or the person you have designated/chosen as your advocate. This form gives us permission to discuss the necessary information with the appropriate church staff and concerned parties in regards to your situation in accordance with the below confidentiality guidelines.

Please be assured that our counselors strongly prefer not to disclose personal information to others, and we will help you find ways to resolve a problem as privately as possible.

RESOLUTION OF CONFLICTS
On very rare occasions, a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts are resolved in a biblical manner, we require all of our counselees to agree that any dispute that arises with a counselor or with Twelve Stones staff as a result of counseling will be settled by mediation from a third party; our board of directors, and/or leadership from your church. We will make every effort to resolve conflict in a manner according to the principles of scripture and under the authority of the local church.

HAVING CLARIFIED THE PRINCIPLES AND POLICIES OF OUR COUNSELING MINISTRY, WE WELCOME THE OPPORTUNITY TO MINISTER TO YOU IN THE NAME OF CHRIST. WE DESIRE TO BE USED BY GOD AS HE HELPS YOU TO GROW IN SPIRITUAL MATURITY AND PREPARES YOU FOR USEFULNESS IN HIS BODY.

IF THESE GUIDELINES ARE ACCEPTABLE TO YOU, PLEASE SIGN BELOW.

Electronic Signature*

Once you click "SUBMIT" you will have completed the application!

An email will be sent to your advocate shortly. Please let them know they will be receiving an email in reference to your time at Twelve Stones.

We will review your paperwork to ensure we have everything we need to care for you well.
Once all forms (including advocate forms) are received, we will be able to discuss tentative dates with you regarding your time on our campus.

Once dates have been selected, a payment must be made to reserve the selected dates on our calendar.

After the appointment is scheduled and payment was made, we will discuss with you all logistical details regarding your time with us.

Thank you again for diligently completing these forms.
May our Lord do great things in your life as you continue to draw closer to Him.

Warmly,
Your Twelve Stones Team

Name

This field is for validation purposes and should be left unchanged.

Frequently Asked Questions

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Which retreat is right for me?

*If married, we highly recommend your spouse is with you the entirety of the time with us.

We offer three types of tailored retreats to meet you where you are in your season of life and ministry (Refresh, Reset, Restore). To determine which retreat is best for you (& your spouse), read below to see which category most accurately describes your situation. Note – If you are torn between two options, choose the one that provides more counseling time.

Refresh Retreats: Helping Leaders to Get Revived Spiritually and Couples to Reconnect

A Refresh Retreat will focus on assessing and rekindling your intimacy with Christ and if married, with each other. Your 3 days will include 5-6 hours of direct counsel and a tailored set of exercises focused on rest, abiding, and deep conservations with your spouse. You will walk out with a renewed sense of closeness with Christ and oneness in your marriage.

If I am honest, my soul is noisy and distracted from abiding in Christ.
I am weary and in need of a time of soul rest.
We could really use a marriage tune up to grow in intimacy.
We need some direction and encouragement to lead healthy in ministry.
We have some marriage or family issues we could use counseling for.

Reset Retreats: Helping Leaders Correct Priorities and Couples to Thrive In Ministry Partnership

A Reset Retreat is more about an honest look at priorities and rhythms. While there is times of rest and refreshment, there will be 8-10 hours of direct counsel to assess and adjust habits that are not congruent with leading healthy and creating sustainable rhythms for life and ministry. You will build a Lead Healthy Plan© with your spouse and walk out with a clear sense of how to thrive as a leader and as a couple partnering in ministry. Advocates can be so helpful as you implement new habits and are strongly recommended for this level of counsel.

I have let urgent overshadow what’s important.
I find myself leading reactively more than proactively.
I need to establish healthier rhythms in my life.
My marriage has, at times, taken a back seat to ministry.
We need to develop some goals as a couple to help us to thrive in ministry.

Restore Retreats: Helping Leaders to Address Heart Issues and Couples to Get Healing

A Restore Retreat is the most intensive of the three. The focus is on getting after heart issues hindering healthy leadership, finding hope again after significant loss, working through a strained marriage, a leader conflict, or ministry exhaustion. The direct counseling time will be 14-16 hours and includes the support of advocates.

I think I have several signs of burnout.
I have significant conflict in my life.
I am struggling with past loss, rejections, or betrayal.
I have some unhealthy habits that are at times, debilitating.
We are struggling to know where to turn for help in a very difficult time of marriage.

Ready to register? Click Here.

If you are still unsure, please give us a call, we are here to help you determine what would be best for you: (866) 304-2320.

What is an advocate and why do I need one?

An advocate is a friend from back home who sits through the entire counseling process and then returns home to help you live out what you learned.

In our experience, the presence of an advocate drastically improves the success of what takes place in counseling and after. Many times, those in crisis have been isolated from the community. Advocates help to bring them back into a healthy, biblical community. They care for you deeply and will be a friend, guide, and encouragement through your toughest days.

If you can’t find an advocate, contact us and we will help you consider who can serve as your advocate.

What is the payment process?

Once dates have been confirmed, we will send out an invoice that can be paid online via credit card or automatic bank draft. Full payment is due 30 days before the first day of the scheduled counseling dates. For more detailed information, please view our financial policy page.

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Frequently Asked Questions

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Which retreat is right for me?

What is an advocate and why do I need one?

What is the payment process?

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866-304-2320 | susan@twelvestones.org | 2727B West 166th Street | Westfield, IN 46074