• Please complete the following questions to be matched with a counselor.

  • Personal Information

  • Where do you reside?*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Church Membership*

  • Counseling Preferences

  • Type of counseling needed (Please select one):*
  • Reason(s) for counseling request:*

  • Personal Preference in Counselor

  • Counselor gender:*

  • Membership & Payment Option

  • Please select one that is applicable*

  • Please note that this is strictly a referral to independent counselors and/or counseling centers, and there is no guarantee that you will be matched with a LCN networked counselor. 

  • If you are an official member of an LCN network church, you may reapply every year to receive additional 10 sessions at the fixed lowered rate and the subsidy support. This renewal begins at the beginning of the year in January.

  • Late cancellation fee: If you cancel the scheduled appointment less than 24 hours notice, you will be responsible for a $50 fee.

  • Additional Information

  • Applying for a minor: If you are a minor (under the age 18) or you are applying on behalf of a minor, please provide a guardian's name and relationship to the applicant.

  • Is the applicant a pastor or a pastor's immediate family member?
  • Is the applicant informed and willing to receive counseling?

  • Additional Information

  • Have you used LCN services before, and are you reapplying?

  • If you do not contact your LCN counselor within two weeks of being matched, we cannot guarantee that the same counselor will be available for you. 

     

    Thank you.

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