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Interest Form
This form is to indicate interest in having the church sponsor counseling. If you or someone you know is in crisis, please contact the Suicide Prevention Lifeline at 988 or 1-800-273-TALK (8255), or dial 911 in case of emergency.
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* Indicates required question
Disclaimer: The information collected here is only available to the Coordinator of the Mental Health Program.
Your answer
Name
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Address
Your answer
Will you be attending the bimonthly Mental Health Clinics?
*
Yes
No
Please indicate the type of counseling you are interested in:
*
Individual
Group
Family
Couples
Other:
Required
Please indicate areas of concern:
*
Life Adjustment / Transition
Anxiety / Stress
Behavioral / Mood Changes (Depression)
Anger Management
Parenting
Alcohol / Other Drugs
Eating Concerns / Self-Esteem / Body Image
Grief and Loss
Relationship Conflicts
Spirituality
Other:
Required
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