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CONFIDENTIALITY AND INFORMED CONSENT

All communications, records and results will be held in strict confidence. Information concerning you will not be shared with anyone unless you have authorized and signed a written release of information indicating informed consent to such release.

Request for Consultation:

To assist me in evaluating your request, please complete the following information:

Name
Phone
E-mail


Request For: 

Are you currently seeing another counselor?  Yes    No

Are you currently taking any prescribed medication?   Yes    No

If Yes, please list name of medication and for what reason:

Why are you requesting Christian Counseling?

Best Day and Time to contact you?        By Email    By Telephone

I will review your request and contact you by email or telephone to schedule your initial consultation.

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