Confidential Interest Counseling Form
We are SO excited you are taking this step. We would love to learn a little more about you before we get started. Please complete this interest form.  All of the information submitted is confidential and will only be seen by the Life Interconnected team for the purpose of determining if our services would be a good fit, unless disclosure of this information is required by law.

At Life Interconnected, we offer pastoral counseling through our holistic and faith-based approach.  All of our christian counselors hold a master's degree and have received training in spiritual formation.   Submitting an interest form does not guarantee acceptance as a counseling client.  We are not licensed mental health counselors.  If you are having an immediate or urgent concern or crisis, please call 911.  If you have any issues with the form or follow-up questions, you may contact us at hello@lifeinterconnected.com.  We will do our best to respond to your inquiry within one week.  
                                                                                            
                                                                                                Sincerely,
                                                                                                Life Interconnected Team
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Email *
Hello, what is your name? *
What is your phone number? *
What City and State do you live in? *
Are you eighteen years or older? *

We do not accept insurance at this time, cash/credit card only. The rate for a 60 minute session is $140.

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What brings you to counseling at this time? *
How did you hear about us?
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What is your availability for counseling?  Morning, Afternoon or Evening? *
Are you seeking virtual or in person counseling? *
What is the urgency of your counseling needs? *
Which of the following categories apply to you? (Check all that apply)
Would you like to be added to Life Interconnected email list to receive our monthly newsletter, including info about workshops, counseling groups and new podcast episodes? *
Somatic Breathwork Offerings
We are excited to share our Somatic Breathwork offerings with you! Please answer the following questions to help us understand your interest and how we can best support you in this area. Somatic Breathwork is a powerful practice that helps reconnect the body to the mind, promoting emotional release, stress reduction, and overall well-being. It can be a transformative ability for healing and self-discovery.
Are you familiar with the benefits of Somatic Breathwork?
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What are your personal goals for this next season of healing?
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Do you have any other questions for us?
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