Family Counseling Intake Questionnaire

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Thank you for signing up for a counseling session(s). The information you provide in this form is used to determine how best to meet your needs. Please complete the form below. You must complete this questionnaire prior to attending a session.

Full Name *

Spouses Name (if applicable)

How long have you been married/together?

List Name of Children (gender/age)

Email *

Phone

Are you a member of Zion Church? *

Yes

If you are a member of Zion Church, which campus are you affiliated with and how?

Zion Anywhere member

Zion Anywhere viewer

Zion Woodbridge member

Zion Woodbridge attender

Zion Greenbelt member

Zion Greenbelt attender

Zion Landover member

Zion Landover attender

Zion Fort Washington member

Zion Fort Washington attender

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Please Check Days/Times of Availability (check all that apply) *

Saturdays/Mornings

Mondays/During the day

Tuesdays/During the day

Wednesdays/During the day

Thursdays/During the day

Thursdays/Evenings

Sundays/Afternoon

Required

Are you okay with online counseling? *

Yes

Other:

Please select who you would like to counsel you *

Eric Kellum ($65 per )

Susan Kellum ($65 per session)

Eric and Susan Kellum ($100 per session)

Why did you choose to sign up for counseling session? *

What do you hope to gain from counseling with Pastor Eric? *

Is there any additional information that you think may be helpful? *

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