Hope for Life Ministry and Counseling Intake Form
Email address *
Today's Date *
Name *
Address *
City *
State *
zip *
Cell Phone Number *
Home Phone *
Birthday *
Age *
Emergency Contact Name and Phone Number *
Occupation and Employer/School *
Gender *
Married/Single *
How many children and ages? *
Place of worship? *
Physician's name? *
What medication are you taking and amount? *
Why are you seeking counseling? *
How did you hear about us? *
By typing you name below you are agreeing to these terms. I agree to pay $140 per session (:50 min). I understand that Steve will hold all information as confidential except in the case of church discipline. I understand that Steve Leavitt, while having a master in counseling, is not licensed by the state of Texas and does not hold himself out as a professional counselor but as a pastoral biblical counselor. *
A copy of your responses will be emailed to the address you provided.
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