Temple Church - New Bern - Request Counseling

Request a Counseling Session

Contact

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First Name

Last Name

Email

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

What methods of communication do you prefer concerning your inquiry?
Phone Call
Text
E-mail

Can we leave a voicemail?
Yes
No

What is your relationship status?
Single
Engaged
Married
Divorced
Widowed

What is your significant other's name?

If separated or divorced, how long? (optional)

How long ago did you lose your spouse?

Do you have children?
No
Yes

Tell us about your children (Name, Gender. Age) (optional)

Emergency contact's first & last name.

Emergency contact's phone number.

Relationship to the emergency contact?

Do you attend church?
Yes
No

Where do you attend church?

Have you had counseling before?
No
Yes

Please tell us about your past counseling experiences (Answering Where/When/Who/Why).

Are you seeing a psychiatrist?
No
Yes

Please provide the name of the psychiatrist.

State the nature of the problem in your own words.

Do you currently have suicidal thoughts, feelings, or actions?
No
Yes

Tell us more about these feelings.

Do you have any past hospitalizations, incarcerations, or suicidal/assaultive behavior?
No
Yes

Tell us more about these events.

Best time to attend counseling?

How did you hear about us?