Debriefing Application form – South Africa Debriefing

Please fill in the debriefing application form below:

Name *

First

Last

Date of birth:

YYYY/MM/DD

Gender:

Nationality:

Marital Status:

Email address:

Phone number:

Address:

City, Country serving in

Organisation

Title/Role in Organisation

Total years/months in the field

Length of stay on field this term

Preferred Language for debriefing:

Other than “someone recommended it”, why do you think you need debriefing?

Please be specific.

If you are currently home from the mission field, what were the reasons for coming home?

Is this your first Exchange at the Cross debriefing?

If No, when and where was your previous debriefing?

Please indicate when you would like the debriefing to take place.

The duration of the debriefing will be 4,5 days

Are you taking any prescribed medications?

If yes, please explain:

Are you under the care of a professional psychologist or psychiatrist?

If you answered yes in the question above, please explain:

Which church/congregation is responsible for your release to the mission field?

In case of an emergency, who will be the contact person at your church?

Kindly provide a name, E-mail address as well as a telephone number.

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