Client Intake | CV Biblical Counseling Center

Name of Client *

First

Last

Date of Birth *

Home Phone

Gender *

Male
Female

Cell Phone

Preferred method of contact *

Text
Email
Phone

Preferred method of session *

In person
Virtual

Address (street, city, state, & zip)

Address Line 1

Address Line 2

City

State

Zip Code

counselor their Agency

Email Address

Marital Status *

Who referred you to us?

Church
Physician
Agency

Agency (if Agency)

Type of counseling *

Individual
Family
Premarital
Marital

Place of Employment

Reason for seeking counseling *

If requesting a specific counselor please list their name

Our standard session fee is $80. Payment plans or other forms of assistance may be available and will be discussed with you during your visit.

CV Biblical Counseling is a non-profit center dedicated to providing Biblical Counseling. Our Counselors are NOT Licensed Professional Counselors (LPC) and as such we cannot bill or accept payment from insurance companies.

Please be aware our Counselors use the Holy Bible (God’s written word) as the foundation for counseling and will help you use God and His Word as you navigate your journey through difficulties.