Name *
Name
Permission to call? *
Permission to text? *
Permission to leave voicemail? *
If married couple seeking counseling together. Individuals put N/A.
If married couple seeking counseling together. Individuals put N/A.
If married couple seeking counseling together. Individuals put N/A.
If married couple seeking counseling together. Individuals put N/A.
If married couple seeking counseling together. Individuals put N/A.
Marital Status *
If no children put N/A
Are you a member of In Focus Church? *
Are you part of a small group at In Focus Church? *
Do you profess faith in Jesus Christ as your Savior and Lord? *
Please rate your health in the following areas:
Are you currently seeing an attorney or involved in any legal matters regarding your situation? *
Have you had counseling or therapy in the past? *
Are you currently seeing a counselor or psychiatrist for this issue or another? *
Please rate any of the following symptoms you are currently experiencing
0 - Not experiencing 1 - Rarely 2 - Sometimes 3 - Frequently 4 - Most of the time 5 - Always