“…but wisdom is found in those who take counsel.” - Proverbs 13:10

This form helps us understand your specific needs and how we can begin praying and preparing for our initial session.

Name of person seeking counseling

First Name

Last Name

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Email

Phone

(###)

###

####

Type of Counseling

Primary Concern

Description

Please, describe in detail your reasons for seeking counseling?

Have you sought counseling in the past regarding this issue?

Yes

No