Request for Services 
 Online request for peer coaching services
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メールアドレス *
We are so glad you are reaching out! We are excited to launch our Jesus-centered emotional health and recovery support services! 

If this is an emergency please contact 911 or call 988 for crises services. We do not provide emergency or crises services.

Peer coaches are trained to be a listening ear, a coach, and a guide for the person to experience emotional and spiritual healing from the person of Jesus. Peer coaches have experienced and overcome similar challenges and have been trained to help others. They meet for a wide variety reasons including, worry, anxiety, sadness, depression, addiction, and other problems we are faced with in life.

They meet for one on one sessions for one hour, weekly for approximately four sessions. These services are free. Please know that the peer coaches are not professional counselors but are supervised to provide quality care. 

This information is confidential and your information will not be shared.
What services are you interested in  *
必須
First & Last Name *
Phone number *
Age  *
Gender *
Marital Status *
 Race or Ethnicity *
Education *
What insurance do you have? This helps if professional counseling services are desired.  *
必須
Occupation *
Who referred you to this service? *
Do you attend Canyon View Vineyard Church *
If you dontattend Canyon View Vineyard Church, where do you attend?
How often do you attend church? *
Are you a part of a Life Group or volunteer community?
 *
How would you describe your spiritual journey currently?
What is the current issue you are wanting to address?

On a scale of 0-10, 0 being no distress and 10 being the most distressed. How would you describe the level of distress this issue(s) is causing you in the last 30 days? 

No Distress
Extremely Distressed
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How important is it to you to make a change regarding this, on a scale of 0 to 10 with 10 being extremely important?

Not Important
Extremely Important
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How confident are you that you can make a change, on a scale of 0 to 10 with 10 being extremely confident?

Not Confident
Extremely Confident
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Briefly describe your history with mental health and any addiction (Please provide professional services or interventions and diagnosis). *
This is useful for determining the appropriateness for the program 
Are you currently receiving mental health or addiction treatment? (Please describe or put N/A if not applicable).
 *
Are you experiencing current suicidal or homicidal thoughts?
 *
In the past month, please select the areas of concern for yourself and your family
 *
必須
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