Assemblies of God Potomac Ministry Network Information Form
Date
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Month
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Day
Year
Date
Minister's Name
*
First Name
Last Name
Minister's Email
*
example@example.com
Minister's Phone Number
*
Please enter a valid phone number.
Ministry License Number
*
This form is for the purpose of requesting counseling sessions. This information will be held confidential, and the client gives consent for Genesis Counseling Center (“Genesis”) to invoice the Assemblies of God (“A/G”) Potomac Ministry Network for pre-approved counseling services. A/G is willing to assist in funding the counseling services. If the client does not attend a scheduled appointment and does not cancel appropriately, the client is responsible for the missed appointment fee. Genesis will attempt to bill the client’s insurance, if appropriate. If insurance payment is authorized, Genesis will only bill A/G for the client’s portion amount, which may vary depending on insurance. A/G agrees to pay up to $95 per session for 3 counseling sessions.
Client's Signature
After submitting this form, you will be automatically directed to the Genesis Request Services form for counseling. This form will officially start the process to get you connected to a Genesis counselor. One of our Client Care Coordinators will contact you after you have completed this form to discuss next steps. You can use the Chat feature on our website to ask questions and get additional information. Thanks for the opportunity to serve you and your work in ministry!
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