CCCC Client Initial Screening Form
Please complete our Counseling Center Initial Screening form to better understand your needs and find you a clinician that can support you best at this time.
Name *
Email *
Address *
Phone number *
Can we leave a text message? *
Required
Can we leave a voice message? *
Required
Location Preference for Services *
Required
Availability for services- Share the timeframe you are seeking to schedule your sessions *
Required
Availability for services- Share the day of the week you are seeking to schedule your sessions *
Monday
Tuesday
Wednesday
Thursday
Friday
Sunday
Sessions
Through our offices we host clinical practicum students who are supervised by licensed clinical professionals. For those open to consider working with our clinical candidates their services are free. Would you be willing to be seen by one of our clinical candidates? *
Required
If you plan to complete sessions via telehealth, what state will you physically be located during the time of these sessions? *
What type of counseling are you seeking?
Individual
Couples
Marriage
Premarital
Family
Child/Youth
Services
Clear selection
If you selected Couples or Marriage counseling: Share the name of the significant other or spouse, length of time in relationship and phone number. Ex. Jacob Bocaj (10yrs), (333)-333-3333.
If you selected Family or seeking counseling for someone 17 and under: Please share the name/s of your child/ren and the age/s beside each other family member's roles. Ex. Sarah (12) Oldest Sibling; Luke (31)Dad
Do you have any special preferences or expectations ie. male or female therapist (NOTE: Our office can not guarantee our contracted licensed professionals will have these preferences available, but we will do our best to accommodate.)
What is your desired goal for counseling? *
Have you been in counseling before? *
Required
If yes, what was your formal diagnosis?
Are you currently taking any medications? *
List the current medication and dosages you are taking. *
Who referred you to the Collegedale Church Counseling Center? *
Disclaimer
Our office will contact you by email and connect you with your assigned clinician as soon as we process your information. All clinical services through the counseling center are $45. We accept cash, credit, or checks. If you have any further question regarding our services please email us at collegedalecounseling@gmail.com. 
Please confirm that you read the section above *
Required
Thank you for completing this form. I look forward to connecting with you.   
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