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  *
Do we have your permission for your counselor to reach out via text to set up your appointment? *
Availability for Counseling Sessions: *
Required
Seeking counseling in the following area(s): *
Required
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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