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All questions marked by an asterisk are required
Event Name:
Counseling Services Inquiry (Intake)
*First Name:
*Last Name:
*Relationship to the client:
Self
Caregiver (child must be under 18 years of age, request must be made by legal guardian)
Client's Name (If other than yourself):
*Date of Birth:
*Email Address:
*Retype Email Address:
Changing your email address will
not
change your login ID to the new address.
*Phone Number:
*Are you working with a pastor at Resurrection?
Yes
No
*Which pastor have you been working with?
Adam Hamilton
Anne Williams
Cheryl Jefferson Bell
Chris Abel
Chris Holliday
Claire Clough
Darryl Burton
Jason Gant
Joshua Clough
Justin Schoolcraft
Lisa Holliday
Patrick McLaughlin
Penny Ellwood
Scott Chrostek
Steve Langhofer
Tino Hererra
Tom Langhofer
Wendy Lyons Chrostek
Ashley Morgan Kirk
Lauren Baker Thomas
Other
*What type of services are you interested in receiving? :
Individual Counseling
Couples Counseling
Family Counseling
Play Therapy
Premarital Counseling
In additional to our mental health support we have pastors on staff that you could speak with. Please let us know if you would like to meet with a pastor. :
Yes, please have someone contact me about an appointment with a pastor.
No, I would only like to see a counselor at this time.
[Clear selection for question above]
*Which other pastor have you been working with?
*By selecting this box, you understand that Resurrection offers counseling services with graduate student interns at our Leawood location in person or online at no cost. These students are completing their Master's degrees and they are a great resource for those seeking affordable counseling. Interns are under supervision by licensed clinical professionals and are required to video record their sessions for supervision. :
Yes
No
*Please list the preferred zip code or zip codes of the area in which you're looking for counselors:
*Are you currently receiving counseling services with another therapist? :
Yes
No
*Do you have a previous mental health diagnosis? :
yes
no
If yes, what is your current diagnosis? :
Counselors on our list have many different areas of specialty. Please select from the issues listed below to help us identify a counselor suited to your needs:
Addiction
Addiction (loved one)
ADHD
Adoption
Anger
Anxiety
Couples counseling
Depression
Divorce
Eating disorders
Empty Nest
Grief
Infertility
Infidelity
Issues with adolescent
Issues with child
LGBTQ
Parenting/ Co-parenting
Sexual addiction
Sexual addiction (partner)
Trauma
Other
Please describe 'other':
Were you referred to this link by JCCC/VSOC?
Yes
No
[Clear selection for question above]
*Which days and times are you available to meet with an intern?
Monday morning
Monday afternoon
Monday evening
Tuesday morning
Tuesday afternoon
Tuesday evening
Wednesday morning
Wednesday afternoon
Wednesday evening
Thursday morning
Thursday afternoon
Thursday evening
Friday morning
Friday afternoon
Friday evening
*We will be contacting you at the email listed on this form within the next two weeks. Please check that you have correctly entered your email address. If you do not hear from us within this time period, check your junk email. If you do not have an email response from us within two weeks, you can contact krista.gomezgonzalez@cor.org.:
I have confirmed that my email is correct.
Is there anything else that would be helpful for us to know as we try to find referral options for you?
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