Biblical Grief Counseling Intake Form

Biblical Grief Counseling Intake Form

Please complete this form to help us understand your needs. You will be contacted within 24 hours. A counseling fee of $125 is required at the time of your visit.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
What are your Christian Counseling Needs?
Have you previously received counseling?
If yes, please briefly describe your previous counseling experience.
Are you currently taking any medications related to mental health?
If yes, please list the medications.
How would you describe your current situation?
Are you currently part of a church or faith community? If yes, please specify.
What are your goals or hopes for our work together?
Have you or a loved one received a difficult diagnosis/prognosis?
Appointment
Signature
Date

MonthDayYear
Date
Should be Empty: