Adult or Couples Counseling Request
Please use this form to submit a request for INDIVIDUAL ADULT or COUPLES counseling services with Emmaus Road (ERCC). Availability of therapist is not guaranteed, and you will be notified if a waitlist or other referrals are necessary.
First Name *
Last Name *
Birthdate (including year) *
MM
/
DD
/
YYYY
Phone number *
Preferred email address *
Select all options you are available weekly to see a therapist. A therapist will contact you to schedule a specific time. *
Morning (9am-12pm)
Afternoon (12pm to 5pm)
Evening (5pm-8pm)
Not available this day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I'm interested in (type of service)
If submitting for couple counseling, it is necessary to provide your partner's full name and email address:
Were you referred to us through one of our partnerships?
Please note that majority of our services are currently being offered via telehealth in support of social distancing. When we're able to return to in-person meetings, in which location would you be interested? *
If you are a pastor, please let us know at which church/denomination you serve:
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