Counseling Inquiry
Please complete this form to inquire about a counseling appointment at Fellowship of Montgomery.
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Email *
What is your FULL name? *
What is your Date of Birth? *
MM
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DD
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What is your Email? *
What is your Phone Number? *
What is your gender?
What is your address? *
Marital Status
What is it that you are seeking counseling for? (Be as specific as possible) *
How long have you been experiencing this? *
Have you participated in counseling before? *
If you answered yes to the previous question, what was your overall experience in counseling? What were your general results?
In a sentence or two describe your relationship with Jesus. *
How important is your faith to you? *
Not that important
Very important
How does your faith daily influence your life, mentality and responses? *
What kind of struggles have you and/or your family experienced in the past? *
Required
Are you currently taking any medications that are intended to treat any of the above symptoms? If yes, please list them below. *
What is your availability on a regular basis for counseling? *
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