Counseling, Coaching & Mentorship Intake Form
This form is used to request faith-centered counseling, coaching, or mentorship services. All submissions are reviewed prayerfully to discern the most appropriate next step. Submitting this form does not guarantee services.
CONTACT INFORMATION SECTION
Contact Information (all fields are required)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
SERVICE SELECTION
What type of support are you seeking?
*
Counseling Services
Coaching
Mentorship
I’m not sure and would like guidance
GENERAL SUPPORT QUESTION
Briefly describe what brings you to seek support at this time.
*
COUNSELING SECTION
Counseling Services Information
What specific concerns would you like support with?
This request is primarily related to:
Emotional wellness
Relational concerns
Life transition
Spiritual support
Other
Are you currently receiving care from a licensed mental health professional?
Yes
No
COACHING SECTION
Coaching Information
What goals are you hoping to work toward through coaching?
Have you worked with a coach before?
Yes
No
MENTORSHIP SECTION
Mentorship Information
What kind of guidance or covering are you seeking through mentorship?
Are you open to a longer-term commitment?
Yes
No
Not Sure
REQUIRED DISCLAIMER
I understand that counseling services provided are faith-based and do not replace licensed mental health treatment when clinically necessary. I acknowledge that referrals may be made if my needs exceed the scope of services offered.
*
Yes
FINAL ACKNOWLEDGMENT
I confirm that the information provided is accurate to the best of my knowledge.
*
Yes
No
Submit
Should be Empty: