Intake form

Name *

Email address *

Preferred contact method

What are your primary concerns?

Please select at least one option.

Anxiety

Depression

Relationship Issues

Stress Management

Trauma

Personal Growth

How did you hear about us?

What is your age range?

Do you have any previous counseling experience?

Are you currently seeing any other mental health professionals?

What is your availability for sessions?

Please select at least one option.

Weekdays Morning

Weekdays Afternoon

Weekdays Evening

Weekends

What is your preferred session format?

Which service or services are you interested in?

Please select at least one option.

Individual counseling

Couples counseling

Family therapy

Additional questions or comments

Weston Christian counseling center