Southland Counseling Referral Request Form
This form is for you to request a referral to a professional counselor for yourself or your minor child. We will be unable to process requests submitted on behalf of anyone else. You must be 18 years of age or older to complete this form.

If you are currently having thoughts of suicide or are in immediate danger, please call 911.

The information on this form is accessible only to the staff necessary to fulfill your request and will remain confidential.
You will receive a list of Professional Counselors within 3 business days.
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First and Last Name *
Address including street address, city, state and zip code *
Phone Number
Email address *
Re-enter Email Address *
Please re-enter your email address.
Date of Birth - Month, Day and Year *
MM
/
DD
/
YYYY
Gender *
Marital Status *
If you have children, please list their ages.
What is the main reason you are seeking counseling? Include any helpful details. *
When did you first notice this concern? *
Have you previously been through counseling? *
If yes, please list dates, names of counselors and results of your counseling experience.
Are you currently under the care of a psychiatrist? *
Please list any medical or psychological issues that would be important for us to know.
What type of counseling are you interested in? *
Required
Would you prefer a male or female counselor? *
Do you have a specific need for morning, afternoon, evening or weekend appointments? *
Required
Any referral to a counselor is a courtesy, not an endorsement of the counselor or anything he/she may say or advise in a counseling session. Southland Christian Church makes no representation that the counseling provided by a Referral Counselor will meet its standards or agree with its beliefs and teachings. I have read, understand, and will comply with the above policies as terms for my referral to a counselor. I hereby release and discharge and indemnify and hold harmless Southland Christian Church of Lexington, Kentucky, Inc., and any and all individuals, including but not limited to its staff, elders, trustees, employees, agents, from any and all claims, demands, actions, damages, losses or liabilities of any kind which I now have or shall or may have resulting from any advice or service received from any counselor to whom I was referred by Southland Christian Church of Lexington, Kentucky, Inc. *
Required
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