Hope for Life Ministry and Counseling Intake Form
Email address *
Today's Date *
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Name *
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Address *
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City *
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State *
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zip *
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Cell Phone Number *
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Home Phone *
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Birthday *
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Age *
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Emergency Contact Name and Phone Number *
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Occupation and Employer/School *
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Gender *
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Married/Single *
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How many children and ages? *
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Place of worship? *
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Physician's name? *
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What medication are you taking and amount? *
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Why are you seeking counseling? *
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How did you hear about us? *
Your answer
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. *
Your answer
A copy of your responses will be emailed to the address you provided.
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