Counseling Request

Please complete the form below.

First Name

Last Name

Address

Mobile Phone.

Gender

Birthdate

What is your current involvement with 4 Points Church?

Councseling Needs

What led you to seek counseling at this time, and are there any specific spiritual or religious aspects you would like to address?

Briefly describe any previous experience with counseling or therapy, including any pastoral counseling or spiritual guidance, if none, please just list none.

How would you describe your current emotional and spiritual state?

Are there any particular challenges or issues you are facing in your personal, professional, or spiritual life?

Do you have any concerns or symptoms related to mental health or spiritual well-being?

Have you experienced any significant life changes, traumatic events, spiritual experiences, or crises recently?

Are there any coping mechanisms, spiritual practices, or rituals that you currently use to manage stress, difficult emotions, or to nurture your spirituality?

Are you currently taking any medication or receiving treatment for any medical or mental health conditions?

Is there anything else you would like your counselor to know before your first session?

**Consent** By submitting this form, I acknowledge that the information provided is accurate to the best of my knowledge and consent to the use of this information for counseling purposes.

Signature

Todays Date

Counseling Request

Counseling Request

Log-In or Create an Account

New to 4 Points

Next Steps

Resources

Give