Women's Inquiry Form

First and Last Name:
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Age:
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City/State:
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Phone Number:
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Email:
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How did you hear about A Soul Made Well?
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A Family Member
A Friend
Church/Pastor Referral
Counselor's Referral
His Heart Foundation
Instagram Page
Online Search
Restored Nation
Other
Reasons for Seeking Counseling:
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Anxiety
Blended Family Challenges
Dating
Divorce of Parents
Grief or Loss
Growth in Christ
Life Direction/Goals
Life Transitions
Loneliness
Low Self-Esteem
Managing Stressors/Responsibilities
Navigating Interpersonal Relationships
Post-Abortion Support
Toxic Romantic Relationships
Trauma-Related Issues
Other
Use the space below to expand on your reasons for seeking counseling at this time:
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Check Whichever Applies:
High School Student (Public School)
High School Student (Private School)
High School Student (Homeschooled)
High School Student (Running Start)
High School Graduate, Not Attending College
College Student
Attending an Internship/Discipleship Program
College Graduate
Other
If you are a parent, wanting your underage teen daughter to step into counseling, is there a child custody battle going on currently?
Yes
No
Not currently, but there is likely to be one.
Please check all options you're available for counseling sessions: (Please take into account these are Pacific Standard Times)
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I am flexible and will take any timeslot.
Monday Afternoons (2:30 or 3:45)
Monday Evenings (5:15 or 7:15)
Wednesday Mornings (9:30 or 10:45)
Wednesday Afternoons (12:30 or 1:45)
Wednesday Evenings (6:00 or 7:15)
Thursday Afternoons (2:45 or 4:00)
Thursday Evenings (5:30 or 6:45)
Friday Mornings (9:00 or 10:15)
Friday Afternoons (12:00 or 1:15)
Please check your preferred method for meeting:
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In-Person Session
Video Session
Phone Session
I have flexibility to meet in-person or by video/phone
What are your counseling frequency goals to begin with? (NOTE: It is my preference that new clients commit to coming on an every other week basis at a minimum)
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1x per week
Every other week
1x per month
I'm not sure
Use this space to add any additional comments/questions, or provide me with any other information that might be helpful to know.
Please click on the checkbox to continue
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Young Adult Counseling Inquiry

Thank you for your interest in counseling for young women ages 16-24 (girls under 18 are on a case-by-case basis) with A Soul Made Well Pastoral Counseling! Please fill out this form and I will be in touch shortly. Blessings!