Life Enrichment Request

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Dr. Chiquita Miller Johnson is an Ordained Minister, Certified Christian Counselor, and Certified Coaching Specialist with over 35yrs in ministry. Each meeting with Dr. C is designed to enrich your life in order to help you have the life God has for you. Life Enrichment sessions are available weekly, bi-weekly, monthly or as needed, either in person or virtually. Please complete this form to request services.

Email *

Name *

Date of Birth *

YYYY

Phone number *

Address *

Have you received any counseling or coaching services before? *

Yes

Required

If Yes please describe why you are looking for a new counselor and/or Life Coach.

Have you been diagnosed with any of the following? (Please check all that apply) *

Bi Polar

Depression

Schizophrenia

PTSD

None of the above

Other:

Required

Please check any of the following that applies to you. *

Anger Issues

Anxiety

Alcholism

Child Abuse victim

Cutting

Domestic Violence

Drug Addictions

Drug Use

Eating Disorder

Feeling Hopeless

Health Issues

Homicidal Thoughts (Want to harm others)

Incest

Insomnia

Molestation

Rape Victim

Suicidal Thoughts

Suicide Attempt

None of the above

Other traumatic experience (You may explain when we meet)

Required

Please give a brief description of why your are seeking counseling or coaching services. *

What are your biggest concerns about beginning this process?

How often would you like to meet? *

Weekly

Every Two Weeks

Once a Month

One Time Consultation

As Needed

Best day AND time available. Please list at least 3 options in the order of preference. *

Please Select your Time Zone *

Pacific PST

Mountain MST

Central CST

Eastern EST

What is your preferred date to begin? *

Meeting Preference? *

In Person (This option is temporarily Unavailable)

Virtual

All Sessions are currently Virtual. Will you be able to meet via ZOOM? *

YES

Required

All services are private pay. Please select how you would like to pay. *

$50 Per session due the day of appointment

$45 Automatic Pay per session (This allows you to set up weekly discounted ACH transactions to occur if you commit to at least 4 sessions)

One Time Payment for minimum of 4 wks - 1hr sessions at discounted rate of $160 ($40/session)

Notice of Confidentiality Statement *

Please know that ALL matters discussed in your sessions are highly confidential and will not be disclosed without your consent to anyone. The only exception to this is if you are a danger to yourself (suicidal) or to others (homicidal). Those are two circumstances in which I am required by law to report to the proper authorities. ***By typing your full name you are acknowledging that you have been informed of the privacy policy.

Consent to receive Christian Counseling and/or Life Coaching from Dr. Chiquita Miller Johnson *

By your signature you agree to give consent to receive Faith Based Counseling which will involve the appropriate use of Prayer and practical application of spiritual principles according to the Holy Bible as The Word of God. *Please nter your full name and date to represent your signature

Send me a copy of my responses.

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