Counseling Form Name * First Name Last Name Email * Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Monthly Household Income * Number of Dependents * Financial burdens or additional information How much of a session would you be comfortable paying for? * What lead you to seeking support? * Are you currently seeing a counselor of any kind? * Yes No Have you sought counseling in the past? * Yes No Which area(s) of counseling? Individual Group Therapy Couples Counseling Retreat Life Coaching Do you feel that you have a good support system? (ex. Family, church, friends) Yes No Would you be open to having a Prayer Partner through? A member of the Faithfully Restored Community who would be specifically praying for you and send you notes of encouragement. Yes No How did you hear about Faithfully Restored? Friend Social Media Internet Search Church Other Thank you! Find this form overwhelming? We are happy to help, email here.
