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 NameLast Name
E-mail*
Phone*
Address*

Street Address

Street Address Line 2

CityState / 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/hr for Eric and Jane, and $90/hr for Clyde. 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 JourneyMajor Loss / GriefMarital CounselingFamily CounselingAnxiety / Panic AttacksAnger IssuesIllness / PainDepression / LonelinessSexualityAlcohol AddictionDrug AddictionGambling AddictionPornography AddictionOther
Please provide a brief description of your reason for requesting counseling.
How often would you like to receive counseling?*

WeeklyEvery-Other WeekMonthlyOther
Which counselor would you like to request?*
Jane Boyd & Eric Johnson are available for weekly counseling sessions onsite at Ebenezer with a fee of $60/hr. Clyde Bomgardner is usually available upon request, but typically meets for counseling at Calvary BFC in Coopersburg or at his office in Palmyra with a fee of $90/hr. (Clyde may be able to travel to Ebenezer if needed.)
What is your availability? Please list days/times that work best for you.*
Should be Empty: