EmailMe Form - Counseling Request Intake Questionnaire

Name *

First Last

Date of Birth *

MM / DD / YYYY

Address *

Street Address City State / Province / Region Postal / Zip Code

Best Phone Number *

### - ### - ####

Please share the best phone number to contact you/leave a message.

Primary Email *

Confirm

How would you prefer that we contact you? *

By email.

By phone. Below is the best time to call me.

Do you attend Lighthouse on a regular basis? *

Yes

No. I do not attend church on a regular basis.

No. I attend another church on a regular basis.

Regular basis = at least once a month.

How long have you been attending Lighthouse? *

Are you a member of Lighthouse Christian Center? *

Yes

No

What is the name of the church you regularly attend?

Marital Status *

How long have you been married? *

Are you currently living together? *

Yes

No

How long have you been living together? *

Who will be coming in for the appointment? *

Just me.

I will bring the following people with me:

Do you have children living at home? *

Yes

No

Please list your child(ren)'s name(s) and age(s). *

Check resources/people who support you. *

What prompted you to seek counseling at this time? *

Have you previously talked with someone on the counseling team about meeting for counseling? If yes, with whom did you speak? *

Please share briefly how you believe our counseling team can best help you. *

What day(s) are best for you to meet with someone on our counseling team?

**Please note: Counseling appointments are scheduled between the hours of 9:00am and 5:00pm. *

What is the best time of day for you to meet with someone on our counseling team?

**Please note: Counseling appointments are scheduled between the hours of 9:00am and 5:00pm. *

HH : MM AM/PM

Thank you for taking the time to provide answers to these questions. We will contact you as soon as possible.

PLEASE NOTE: if you get a blank screen after submitting your form, please scroll up to the top of the page. You will be prompted to complete missing fields before resubmitting your form.