CHM Biblical Counseling Intake Form
Thank you for choosing CHM for Biblical Counseling! Please complete all answers to the best of your ability.
Please note that all counseling sessions are 45-55 minutes and the fee is $100 per session. If finances are a concern,  please contact our office at counseling@choosinghimministries.org to inquire about assistance.
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What location do you prefer? *
Last Name  *
First Name  *
How did you hear about Choosing Him Ministries?  *
Were you referred by a Pastoral Staff, if yes, please list referring staff member. if not, put n/a *
Date of Birth *
MM
/
DD
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YYYY
Email *
Phone Number  *
Emergency Contact: Name (Last, First)
Emergency Contact: Relationship to Client 
Emergency Contact: Phone Number 
Marital Status  *
Availability for Counseling Sessions: *
Required
Seeking counseling in the following area(s): *
Required
Have you ever utilized counseling services in the past? If so, please explain.  *
Are you currently on any prescribed medication? If yes, please list all. If no, type "N/A"  *
What are your primary goals for counseling with CHM?  *
Do you have any other pertinent information you would like to share?  *
Do you have a particular counselor you would like to request? *
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