Epiphany Brooklyn Biblical Counseling Intake Form

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Thank you for taking the time to fill out this form, to ensure our counselors have the background information they need to support you best. Fill out each section to the best of your ability and a counselor will reach out to you within 3-5 business days to set up a meeting time. All sessions are VIRTUAL at this time.

Today's Date *

YYYY

Name *

Email *

Phone *

Do you attend Epiphany Church Brooklyn *

Yes

Other:

Are you a member at Epiphany Church Brooklyn? *

Yes

Church Involvement (Please select all that apply) *

Part of a small group

Serving on a ministry team (e.g. including but not limited to: community life team, welcome team, worship team, tech team)

Undergone Foundations of the Faith or God Seekers class

Currently in a discipleship group (DNA, discipling or being discipled)

Leading a ministry

Not serving but interested

Not currently serving

Other:

Required

Any mental health history? *

Yes

Unsure

If yes, please describe below. If none, write N/A below. *

State the reason why you're seeking counseling. Please be as detailed as possible. *

What goals do you have for counseling? *

Are you able or comfortable paying out of pocket for counseling services? *

Yes

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