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?
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