Counselling Request

We are here to support you. Please fill out the form below to request counselling from our pastoral care team. All information shared will be kept confidential.

Full Name(*)

Please supply your Name

Email Address(*)

Please supply a valid email address

Phone Number(*)

Please supply a valid Phone Number

Preferred Method of Contact(*)

Email

Phone Call

Text Message

Please select a response

(Check all that apply)

Are you a member of our church?(*)

YesNo

Please select a response

Are you born again?(*)

YesNo

Please select a response

What type of counselling are you seeking?(*)

Please briefly describe the reason for your counselling request(*)

Please supply counselling request

Have you received counselling before?(*)

YesNo

Please select a response

If yes, please provide details (optional)

What days are you available for counselling?(*)

What times are you available for counselling?(*)

Morning (9 AM - 12 PM)

Afternoon (12 PM - 4 PM)

Evening (4 PM - 7 PM)

Please select a response

(Check all that apply)

Do you prefer in-person or virtual counselling?(*)

In-Person

Virtual (Video Call)

No Preference

Please select a response

(Check all that apply)

Is there anything else you would like us to know?

CONFIDENTIALITY AGREEMENT
By submitting this form, you acknowledge that:

All information provided will be kept confidential and shared only with the pastoral care team.
Our team will contact you to schedule a session based on your availability.
If this is an emergency, please contact a local crisis hotline or seek immediate assistance.

Counselling Request Form