..:: Learning Stream ::..

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:

*Phone Number:

*Are you working with a pastor at Resurrection?

Yes
No

*What type of services are you interested in receiving? :

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:

Please describe 'other':

*Which days and times are you available to meet with an intern?

*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?

Save Information:

{Checking this option will save your information for future registrations}