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Life Counseling Ministries -- Confidential Counseling Inquiry Form
Please fill out this form and someone will respond within 1-2 business days.
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* Indicates required question
Name:
*
Your answer
Age:
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Your answer
Phone number:
*
Your answer
Email
*
Your answer
Can we leave a voicemail?
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Yes
No
Contact Preference:
Email
Phone
Clear selection
Spouses Name (for couples counseling):
Your answer
Spouses' Email Address
Your answer
Spouses' Phone Number
Your answer
City/State of Residence:
*
Your answer
Counseling Preferences:
Individual Counseling
Couples Counseling
Family Therapy
Clear selection
Preference for Counseling Location:
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Marriottsville, MD
Online Video Sessions
In several sentences please summarize what is prompting you to come to counseling and what you would like to focus on:
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Your answer
Are you experiencing suicidal thoughts at this time?
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Yes
No
Other:
Do you have a history of drinking or doing drugs?
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Yes
No
Other:
On a scale of 1 to 10, how distressing do your problems feel today?
1
2
3
4
5
6
7
8
9
10
Clear selection
Availability during the week (e.g. if you prefer mornings, evenings or a specific day of the week), and when you'd like to get started (e.g. as soon as possible, in the next month or so, just gathering information):
*
Your answer
Preference for male or female counselor (we do our best to accommodate but cannot guarantee that your preference will be met)
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Female counselor
Male counselor
Either
If you were referred to a specific counselor, list their name here:
Your answer
Church You Attend / Church Affiliation
*
Your answer
Do you play a leadership role in a ministry?
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Yes
No
If involved in ministry, where and what is your role?
Your answer
Counseling sessions cost $110 per appointment.
Do you have any other questions or concerns about counseling?
Your answer
Our occasional newsletter keeps you updated on groups, events, and other opportunities offered by Life Counseling Center. To subscribe, please retype your email in below. Otherwise, please leave the space blank.
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