Counseling Request Form
Thank you so much for your interest in our counseling services. Please be sure to read this information to understand the next steps involved. You will be asked to answer some basic information about your situation. This is to make sure we can help you and to understand more about the services you are looking for. We are an online counseling program. We operate on a donation based sliding scale, beginning at $25 per session, and then working up to $125 per session. We do everything possible to accommodate all the requests. If there is a waiting list, we will let you know right away. If we do have an opening, we will set up an assessment so you that can ask questions and get set up to start counseling. If you have any questions, please don't hesitate to let us know by contacting Many blessings on your journey of healing!
Email *
First Name *
Last Name *
Phone: (Please provide a number where we can leave a message) *
What is your age? *
Occupation *
Marital Status *
Do you currently attend a local Church? *
If "Yes", what is the name of the Church you most recently attended?
How often do you attend Services, Bible Studies or Small Groups at your local Church? *
Have you asked your Church for help? *
Have you pursued counseling before, for this issue or any other? *
What is your reason for seeking counseling? *
What are your expectations of counseling? *
Is there any other information we should have, either about you or your situation, that you think would be important for us to know prior to meeting with you? *
List any medications you are currently taking. *
How much can you afford to pay for counseling services? (Sliding scale starts at $25 per session and goes up to $125 per session) *
Days & Times you are available for counseling: *
How did you learn about Overcome Ministries Counseling Center? *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy