Midweek Student Counseling Request

For multiple people or for marriage counseling please fill out separate forms for each person

Your name *

Email address *

Phone number *

Gender? *

Birthdate *

Are you currently a Partner at Foothills Church? *

Which location do you attend?

Maryville

Knoxville

Have you had any counseling previously? If so where and with whom? *

Please list the reason for counseling or any important events that may be in relation to this problem. *

Currently taking Medications in relation to mental health? If so, what Medications?

Do you have any medical diagnosis, if so what are they? *

What is your availability? *

Referred by?

The counselor I will be meeting with is a volunteer and takes on no liability in regard to counseling, please sign below by typing your name to agree to this statement. *

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