Counseling Form Name First Name Last Name Email * Phone (###) ### #### Birthday * MM DD YYYY Are you a Covenant Member of Risen Church? * Yes No Emergency Contact Name * First Name Last Name Emergency Contact Number * Communication Your privacy is important to us. If applicable, please list any reasons we should not text, call, email or leave a voicemail when communicating with you What type of counseling are you pursuing? * Individual Counseling Couples Counseling (Married or soon to be married) Family Counseling (2 or more family members) Please share why you are pursuing counseling Briefly share with us the primary goal you hope to obtain from counseling * How would you like to meet with your counselor? In person - at Risen Church Virtually Please select the primary category you would like to discuss in your counseling * General Mental Health (Anxiety, Depression, Anger, Sleep Issues, Stress) Specific Mental Health Conditions (OCD, ADHD, Sensory Processing) Spiritual Struggles/Concerns Marriage Struggles Pre-Marital Mentoring Other If you chose "other," please specify below Please share with us the frequency and felt effectiveness of any counseling or therapy you've participated in over the last 2 years Please share any medications that you are currently taking related to mental or physical health Consent I hereby acknowledge and consent to receive treatment, guidance, or counseling services from Risen Church who has explained that they are not a state-licensed therapist. I understand that they are not providing services as a licensed therapist, but rather are offering biblical counseling. I acknowledge that I am not receiving therapy or mental health counseling services as defined by state laws or regulations, and that any advice or guidance I receive from Risen Church is not intended to replace professional psychological or psychiatric care. I understand that if I require clinical therapy or mental health services, I am encouraged to seek care from a licensed mental health professional and will not hold Risen Church liable. By signing below, I confirm that I am voluntarily engaging in services with full knowledge of the nature, treatment, and qualifications of Risen Church. Thank you for you interest in counseling! We will contact you soon.
