EmailMeForm
Counseling Request Intake Questionnaire
If you are interested in pastoral counseling at Lighthouse, please complete the following form.
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
*
Please select
Single
Dating
Engaged
Married
Separated
Divorced
Widowed
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.
*
Spouse
Parent(s)
Friend(s)
Employer
Doctor(s)
Pastor(s)
Recovery Group
Home Group
Other
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.
*
Monday
Tuesday
Wednesday
Thursday
Friday
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
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.