Counseling Interest Form

Your name *

Last name

Email address *

Phone number *

Phone type

Gender *

Marital status *

What kind of counseling are you interested in? *

Individual counseling

Marriage counseling

Pre-martial counseling

Conflict resolution counseling

Child/Teen counseling

Are you a member of Stonebrook Church? *

Yes

Please provide a brief explanation of the current problem you are seeking counseling for (i.e. grief, anxiety, marriage problems, etc.) *

Note that this interest form will be seen by both the Director of Counseling at Stonebrook and your future counselor. As such, please do not provide specific information that you are not comfortable with both individuals seeing. A more detailed form will be sent to you that will be returned directly to your counselor.

Please provide a brief explanation of what help you are hoping to receive through our counseling service.

Have you already been paired with a counselor? If so, please type your counselor's name below. If not, simply respond with "No."

Is there anything else you would like us to know before connecting you with a counselor?

How did you learn of our counseling services?

Check all that apply

Leadership at Stonebrook Church

A member or attender of Stonebrook Church

From one of our counselors

From an individual who received biblical counseling at Stonebrook

Other

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Stonebrook
office@stonebrook.org
515-232-6290

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