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 *
Your answer
Last Name *
Your answer
Birthdate (including year) *
MM
/
DD
/
YYYY
Phone number *
Your answer
Preferred email address *
Your answer
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 (1pm to 4pm)
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:
Your answer
Were you referred to us through one of our church partnerships?
In which ERCC location are you interested? *
Have you seen a therapist at ERCC before? *
Submit
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