Counseling Request Form

Please provide as much detail as possible. This form is confidential.

Your name *

Email address *

Phone number *

Address *

Birthdate *

Gender *

Marital status *

What type of counseling are you seeking? *

Individual

Marital

Referred by:

Please specify if someone referred you to counseling.

What church do you attend? *

If you do not attend Compass Bible Church, have you sought counseling at your home church?

How often per month do you attend church? *

Where to you serve at church? *

Would you consider yourself a Christian? *

Have you been through Partners (One-on-One Discipleship) *

Answer the following questions

Please provide as much detail as possible.

What problem/issue are you seeking counseling for? *

What have you done about it (have you had prior counseling)? *

Please provide as much detail as possible.

What expectations do you have (how can counseling help)?

List any other information you want the pastor to know:

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.