* Request for Counseling Form *

The information requested is necessary to better understand your counseling goals. Please fill in this form. Please be assured that all information submitted will be kept confidential.  Fields marked with an * are required.

    Your First Name *
    Your Last Name *
    Your Email *
    Address 1 *
    Address 2
    City *
    State *
    Zipcode *

    Home Phone Number*:

    Work Phone Number:

    Cell Phone Number*:

    Marital Status*:MarriedDivorcedSeparatedSingleEngagedWidow

    Membership Status*:ECM MemberNon-ECM Member

    If you are not an ECM member, who referred you?

    Type of counseling requested*:Individual CounselingCouples CounselingMarriage/Pre-Marital CounselingFamily CounselingChild CounselingCo-Parenting Counseling

    Please explain the nature of the counseling session*: