Life Counseling Ministries -- Confidential Counseling Inquiry Form
Please fill out this form and someone will respond within 1-2 business days.
Name: *
Age: *
Phone number: *
Email *
Can we leave a voicemail? *
Contact Preference:
Clear selection
Spouses Name (for couples counseling):
Spouses' Email Address
Spouses' Phone Number
City/State of Residence: *
Counseling Preferences:
Clear selection
Preference for Counseling Location: *
In several sentences please summarize what is prompting you to come to counseling and what you would like to focus on: *
Are you experiencing suicidal thoughts at this time? *
Do you have a history of drinking or doing drugs? *
On a scale of 1 to 10, how distressing do your problems feel today?
Clear selection
Availability during the week (e.g. if you prefer mornings, evenings or a specific day of the week), and when you'd like to get started (e.g. as soon as possible, in the next month or so, just gathering information): *
Preference for male or female counselor (we do our best to accommodate but cannot guarantee that your preference will be met) *
If you were referred to a specific counselor, list their name here:
Church You Attend / Church Affiliation *
Do you play a leadership role in a ministry? *
If involved in ministry, where and what is your role?
Counseling sessions cost $110 per appointment.
Do you have any other questions or concerns about counseling?
Our occasional newsletter keeps you updated on groups, events, and other opportunities offered by Life Counseling Center. To subscribe, please retype your email in below. Otherwise, please leave the space blank.
Never submit passwords through Google Forms.
This form was created inside of Chapelgate Presbyterian Church. Report Abuse