Counseling Request Form
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Thank you so much for your interest in counseling services. Please be sure to read this information to understand the next steps involved.

You will be asked to answer some basic information about your situation. This is to make sure we can help you and to understand more about the services you are looking for.

We are an online counseling center. We operate on a donation based sliding scale, beginning at $25, and then working up to $150 per session. We do everything possible to accommodate all the requests. If we are on a waiting list, we will let you know right away.

If we do have an opening, we will set up an assessment so you can ask questions and get set up to get started!

If you have any questions, please don't hesitate to let us know by contacting info@overcomewithjesus.org.

Many blessings on your journey of healing!
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Email *
First Name
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Last Name
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Phone Number (Please provide a phone number where we can leave a message)
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Age
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Occupation
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Marital Status
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Do you currently attend a local church?
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If "Yes", what is the name of the church?
How often do you attend church services, Bible studies, or small groups?
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What is your reason for seeking counseling?
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Have you asked your church for help?
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Have you pursued counseling in the past for this issue or any other?
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What is your desired outcome from the counseling process?
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List any medications you are currently taking.
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How much can you afford to pay per counseling session? *
Days and times you are available for counseling:
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How did you hear about Overcome Ministries?
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A copy of your responses will be emailed to the address you provided.
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