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CG Midtown Counseling Intake Form
Please complete this form to learn more about counseling assistance options through CG Midtown.
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* Indicates required question
Email
*
Your email
What is your name?
*
Your answer
What is your phone number?
*
Your answer
What is your preferred method of communication?
*
Email
Text
Phone
Do you currently have a counselor?
*
Yes
No
Do you currently attend CG Midtown?
*
Yes
No
Are you seeking a counseling recommendation?
*
Yes
No
Will you need financial assistance?
*
Yes
No
Do you prefer a counselor who accepts insurance?
*
Yes
No
If you answered yes to the previous question, what insurance company do you have?
Your answer
To initiate a counseling referral or financial assistance process, which CG Midtown pastor would you prefer to meet with?
*
Jeff Krajewski
Jim Matthies
Hazel Owens
Cidney Callahan
No preference
Other:
What days and times are you available to meet with a pastor? Meetings can be in-person, virtual, or over the phone.
*
Your answer
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