Counseling Appointment Request

Welcome to Faith Church Counseling Ministry. We take your confidential request for counseling very seriously. Please answer the questions as completely as possible.

Your name *

Email address *

Address *

Phone number *

Is it OK to leave a voicemail on the phone number provided? *

Is it OK to send a text to the phone number provided (if it is a mobile phone)? *

Gender *

Appointment Preference *

Select all that apply

In-Person Only

Willing to do Telehealth (Zoom)

Willing to go on Waitlist

Do you attend to Faith Church? *

What made you contact us today? *

Please provide some detail to help us assign the appropriate counselor.

Do you have thoughts of harming yourself or others? *

Have you received counseling in the past? *

Thank You

The Counseling Pastor will review your request, assign a counselor, and the counselor will call you to review your needs and setup an appointment. Thank you for trusting us with your counseling request.

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