MERCI Mentor Form

MERCI utilizes an assessment and mentoring program called PREPARE-ENRICH. This program is facilitated by experienced married mentors, who are certified in this program. Couples will meet for 6-8 weeks with the goal of returning to the oneness they once enjoyed. Using a variety of trusted principles and tools, couples will re-engage with better communication and conflict resolution skills in all areas of their marriage.

Date

MM

DD

YYYY

Name

First Name

Last Name

Phone

(###)

###

####

Email

Church

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did they hear about MERCI?

Spouse Name

First Name

Last Name

Spouse Phone

(###)

###

####

Spouse Email

Does spouse have the same address?

If not please enter in the "Notes" section below.

Yes

No

Who Took Call

First Name

Last Name

Notes