Name
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First Name
Last Name
Email Address
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Phone
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Please give us a number where we can leave a message.
(###)
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####
Age
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Gender
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Female
Male
Occupation
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Marital Status
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Single
Married
Divorced
Widowed
Do you currently attend a local Church?
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No.
Yes, every week.
Yes, within the last year.
Yes, but I have not attended within the last year.
What is the name of the Church you most recently attended?
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Type "none" if you entered "no" for the question above.
How often do you attend Services, Bible Studies or Small Groups at your local Church?
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None
Occasionally
Rarely
Twice a month
Three times a month
Weekly
Have you asked your Church for help?
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I do not attend a local church.
No.
Yes.
If You have asked or your church for help please share their response. OR If you have not asked your church for help, please explain why not.
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Are you the one that desires counseling or are you seeking counseling on behalf of another person?
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I am seeking the counseling for myself.
I am seeking the counseling for someone else (who is aware of my pursuit for counseling).
I am seeking counseling for someone else (who is unaware of my pursuit for counseling)
I am seeking counseling for myself and my spouse (who is unaware of my pursuit for counseling).
I am seeking counseling for myself and my spouse (who is aware of my pursuit for counseling).
Are you a current Member of North Wake Church?
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No.
Yes.
Have you pursued counseling before for this issue or any other?
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What is your reason for seeking counseling?
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What is the current problem as you see it?
What have you done about this problem up to this point?
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What can we do to serve you? What are you expecting from the HOPE Counseling Center?
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Is there any other information we should have either about you, or your situation that you think would be important for us to know prior to a session with you?
*
How did you learn about HOPE Counseling Center?
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I saw the sign in front of the Church
I found you on the internet
I was referred by a friend
I was referred by my physician
I heard about it at North Wake Church
