Request for Counseling
NOTE: YOUR INFORMATION AND ALL SESSIONS ARE KEPT CONFIDENTIAL.
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What type of counseling do you seek? *
Please note that we will do our best to accommodate you and scheduling is based on the availability of an approved minister.
Required
Your Full Name *
Your Age *
Your Email *
Phone Number  *
May we leave a voice or text message? *
Marital Status *
Spouse's Full Name (if desiring marital counseling)
Spouse's Age (if desiring marital counseling)
Are you a Right Way member? *
Best day for sessions (You may select more than one) *
Please note availability is based on the availability of Pastor V or a qualified minister.
Required
Best time for sessions (You may select more than one) *
Please note that availability is based on the availability of Pastor V or a qualified minister.
Required
Have you completed or attended our Freedom R Group?  *
Describe the problems or issues for which you need counseling (Please be very descriptive and include all details of the problem)  *
When did these problems or issues develop? *
What are you hoping to achieve through counseling? *
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