Form

New Client Form

For best results, please fill in this form 2 days before your first appointment

* Indicates required field

Name *

First

Last

Date of birth *

Phone Number *

For marriage counseling please fill in spouse's name *

First

Last

For marriage counseling please fill in spouse's date of birth *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

1. Reason for counseling *

2. What do you want to achieve through counseling? *

3. Do you attend a church? *

5. I understand that the counseling provided will be based on the Bible *

7. I understand that although suggestions may be given, I am still an individual who is responsible for my own decisions. *

4. If yes, which church? *

6. I understand that I'll be charged 50% of the following session's fees if I cancel fewer than 8 hours before my appointment. *

8. I give permission for all my sessions to be audio-recorded for the protection of the myself and New Heart and Mind. These recordings will be kept private. *

This form will be signed when counseling begins *

Submit