This survey can help us to know how you are doing. All the info given remains confidential.

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* 1. In general, how would you rate your overall mental or emotional health?

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* 2. Which emotion describes you best at this time?

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* 3. My relationship with Father God is...

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* 4. My most challenging area right now is

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* 5. Would you honestly tell us if you needed any assistance?

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* 6. Would you like a call from Pastor?

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* 7. The need in our city is growing by the day. As a church, we would like to help where we can, would you like to be involved?

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* 8. In your opinion, how can the church be relevant at this time?

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* 9. Name and Surname

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* 10. Cell phone number: In case we need to call you

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