Counseling Form

Operation 220 Counseling Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

What is the best way to reach you? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Birthdate *

Name of spouse *

Names and ages of children *

Please tell us why you are seeking counseling *

Please list all the times you are available for counseling. *

Please list any previous counseling by giving the provider, date, and reason. *

Our minimum counseling fee is $75 per hour for individuals and $100 for couples. An average among Christian counseling offices in our area is $90-$100 for couples. An average among Christian counseling offices in our area is $90-$175 per hour.

What is the amount you would like to contribute per hour for counseling? *

I acknowledge the limitations inherent in ensuring confidentiality of information transmitted through online counseling and I agree to waive the privilege of confidentiality with respect to any confidential information transmitted through online counseling that may be assessed by any third party without my authorization and despite the reasonable efforts by the Operation 220 staff to arrange a secure online environment. *

I affirm that I have answered the above questions to the best of my ability. *

How did you hear about Operation 220 Ministries? Please give person and/or ministry name. *

Thank you for entrusting us with your counseling needs. You can expect to hear from us soon.

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Counseling Form

Operation 220 Counseling Form

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