Counseling Request

Counseling Request

Counseling is done in one-hour sessions onsite at Ebenezer Bible Fellowship Church. We warmly welcome anyone to request counseling, whether they attend our church or not. (Financial assistance is available to members & regular attendees.) Please allow 2-4 days for a response to your counseling request.
Name *

First Name Last Name
E-mail *
Phone *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What is your involvement at Ebenezer Bible Fellowship Church? *
Would you like financial assistance in paying for your counseling? *
Financial Assistance is available to Members & Regular Attendees only. The number of sessions for which it is granted will be determined on a case-by-case basis. Cost of counseling sessions is $50-$90 per hour. None of our counselors are able to accept insurance at this time.
Agreement (check the box to agree) *

I understand that to be eligible to receive financial assistance for counseling, I must have attended Ebenezer's Sunday Morning Worship Service at least 16 times in the last 6 months, and agree to maintain this level of attendance throughout the time I am (or a member of my family is) being counseled.
For whom are you requesting counseling? *
Please tell us your child's name & age.
What type of counseling are you requesting? (check all that apply) *

Life Direction / Faith Journey Major Loss / Grief Marital Counseling Family Counseling Anxiety / Panic Attacks Anger Issues Illness / Pain Depression / Loneliness Sexuality Alcohol Addiction Drug Addiction Gambling Addiction Pornography Addiction
Please provide a brief description of your reason for requesting counseling.
How often would you like to receive counseling? *

Weekly Every-Other Week Monthly
Which counselor would you like to request? *
Jane Boyd & Eric Johnson are available for weekly counseling sessions. Clyde Bomgardner is only available to counsel every-other-week on the 2nd & 4th Thursdays of each month, 2-7pm.
What is your availability? Please list days/times that work best for you. *
Should be Empty: