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Counseling Request Form
So that we can best serve you, please fill out the following form, and one of our pastors will contact you shortly.
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Email
*
Your email
Last Name, First Name
Your answer
Cell Phone Number
Your answer
Marriage Status
Single
Married
Separated
Divorced
Widowed
Engaged
Other:
Clear selection
Please describe the nature of the problem the person who is seeking counseling is facing.
Your answer
How long has this been an issue?
Your answer
Where else have you turned for help?
Your answer
Are you committed to following God's will, as He as revealed it to us in the Bible?
Yes
No
Other:
Clear selection
Are you committed to doing the necessary homework between the counseling sessions in order to address the problem?
Yes
No
Other:
Clear selection
I understand that the counseling will be based upon Christian principles as found in the Bible which is the final authority in all cases. If the counselee is unwilling to use the Bible as the final authority or unwilling to do the assigned homework, I understand sessions will be terminated.
Yes
No
Other:
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If you are seeing another pastor/counselor and are okay with us sharing information with one another in order to better serve you, please initial below and leave their contact information.
Your answer
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