Request for Counseling Form

Request for Counseling Form

Submit your request for counseling services with Good Samaritan Ministries. Please complete all sections accurately. Please note: we cannot accept requests for counseling on behalf of another person. The intended client needs to make the request unless the intended client is a minor under the age of 14, or is under the care of a guardian.
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
May we leave a voicemail?
May we send emails?
May we send text messages?
Emergency Contact Name
Relationship to Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Marital Status

Other
Children (Names and Ages)
Have you met with a GSM Counselor previously?
If yes, when?
Name of counselor
What type of counseling are you seeking?

Other
Additional Notes or Special Requests (counselor preferences) - note: due to counselor availability, we cannot accommodate all special requests, though we do our best match clients with best fitting counselors.
Do you prefer virtual or in-person counseling?

Availability for Counseling (select all that apply) Note: the more time you provide as available, the more quickly we can place you with a counselor.