Counseling/Coaching/Mentoring Request
Please complete the form below, and someone will be in contact with you.
Email address *
First Name *
Your answer
Last Name *
Your answer
Marital Status
Your answer
Spouse's Name
Your answer
Children and Ages
Your answer
Phone Number *
Your answer
What type of assistance are you seeking? *
Your answer
Briefly describe your issue. *
Your answer
Are you currently seeing a counselor? *
What were the results of your counseling?
Your answer
If you should experience a behavioral or emotional crisis, please contact emergency service via 911.

Chestnut Ridge LifeCare Ministries will refer to other professionals when issues are beyond the scope of our services.
Volunteers, lay counselors, and coaches with LifeCare Ministries at Chestnut Ridge Church may discuss your involvment and situation with other professional colleagues within Chestnut Ridge Church and/or clinical professionals for referral purposes. Your confidentiality will always be primary importance.

A LIfeCare Pastor or leader may use experiences from your involvment in teachings or writings. Experiences or issues are always used in a general, non-specific way; your name and identity will be kept anonymous.

E-mail or text messaging is not designed to be used for crisis situations, since messages are not monitored on regular basis. LifeCare Ministries at Chestnut Ridge Church will not respond to emails or text messages from people in crisis situations.

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This form was created inside of Chestnut Ridge Church. Report Abuse - Terms of Service