Biblical Counseling Request

Your name *

Last name

Email address *

Birthday *

Gender *

Select…MaleFemale

Phone number *

Phone type

MobileHomeWorkOther

Address *

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Do you attend Church at the Cross? *

Yes

No

Are your current circumstances in any way physically unsafe? *

Yes

No

Are your current circumstances in any way emotionally unsafe? *

Yes

No

What type of counseling are you seeking? *

Individual

Couples

Family

Other

Do you have a preference of gender for a counselor? *

Male

Female

No preference

With what issue or concern are you seeking to get help? How long has this been an issue or concern?

Have you talked to a pastor or staff member about why you'd like to see a counselor? If so, who. *

Are you involved in any groups here at CATC that you have shared this burden with? If so, what group and are you currently experiencing support from them?

Submit

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