Counseling Request Form

Your Name

Telephone #

Please type a brief description of your situation.

Email Address

Type of Counselling (checkmark) Type of Counselling (checkmark) Marriage Counselling Relationship Counselling Family Matters Counselling Struggling-Addictions Counselling Life Other

In which fashion would you prefer? In which fashion would you prefer? In Person Meeting Via Zoom Meeting Via Telephone

Do you attend EKM church? Do you attend EKM church? Yes, I do. I watch online. I do not. But I am planning to attend I visit sometimes. I do not attend EKM church.

Do you call yourself a Christian? Do you call yourself a Christian? Yes, I do. No, I don't. Other.