Pastoral Counseling Form

Work Entry

Added: 4/30/2024

Pastoral Counseling Request

Please complete the following form to request an appointment. As a reminder, this is Pastoral Counseling, not professional or licensed care.

First Name

Last Name

Phone

I am over the age of 18. Choose Yes or No.

If not over the age of 18 please provide the following

Parent Name

Parent Phone Number

Parent Email

What day(s) work best for you?

Monday Tuesday Wednesday Thursday Any day

What time of day works best for you?

I am seeking:

For a couple's session please provide the name of the spouse/partner participating

Please provide a brief description of what you are seeking counseling for.

General Description of the need for Pastoral Counseling

I understand childcare is not provided and children are not to be unattended anywhere in the building or offices while parents are in session.

I understand this is Pastoral Counseling with a lay counselor, not professional or licensed care.

Once your request form is submitted, you will receive an email response from pastoralcounseling@southbrook.org (please add this email to your contact list to ensure email response is received).
Appointment requests are responded to within 24 hours, Monday - Thursday

Submit