counseling form

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Best Method of Contact*



Marital Status*

Rate Your Health*

Are you presently taking medication?*

Have you ever experienced severe emotional trauma?*

Have you recently suffered the loss of someone who was close to you?*

Have you recently suffered a loss from serious social, business or other reversals?*

Do you consider yourself a religious person?*

Do you believe in God?*

Do you question your salvation?*

Do you pray to God?*

Do you have a regular daily devotion?*

Has there been any recent changes in your religious life?*

Have you ever had any psychotherapy or counseling before?*

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Is your spouse willing to receive counseling?

What day would work best for your appointment? (Appointments available from 9:30am - 5pm)*