Request for Counselling Form
Thank you for your interest in St. John’s – St. Margaret’s Counselling Ministry. Please complete the details below to allow us to get in contact with you. All requests are kept strictly confidential. Questions with * are required. Thanks!
Name
*
First Name
Surname Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
What is your gender?
*
Female
Male
Who is this request for?
*
Myself
Myself and someone else (couples/family)
For my child
What is the age(s) of the client(s)?
*
What is your relationship status?
*
Single
In a relationship
Married
Separated
Divorced
Widowed
Do you attend SJSM?
*
Yes
No
Were you referred to us by someone? If so, who? If not, how did you find out about us?
*
Type a question
*
Privacy PolicyBy completing and returning this form, you consent to St. John’s – St. Margaret’s Church’s collection, use and disclosure of your personal data (and/or the personal data of any person on whose behalf you are validly acting for or authorized to provide consent) for our church activities, programs and administration purposes in accordance with St John’s – St. Margaret’s Church’s Personal Data Protection Policy. A copy of the Personal Data Protection Policy is available at our administration office.
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