Temple Church - New Bern - Request Counseling

Request a Counseling Session

Personal Information

Contact

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First Name

Last Name

Email

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

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Marital Status

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First and Last Name

If separated or divorced, how long? (optional)

Children (Name, Gender. Age) (optional)

Attend church? if so, where?

Prior Counseling?

Are you seeing a psychiatrist?

How did you hear about us?

Emergency Contact (Name, phone number and relationship)

Best time to attend counseling?

State the nature of the problem in your own words.

Any current suicidal thoughts, feelings, or actions? If yes, explain.

Any past problems, hospitalizations, or jailings for suicidal or assaultive behavior?