First Name

Last Name

Email Address

Phone Number

Subject

Type of Counseling Type of Counseling Individual Couples Family Neurofeedback Groups (Marriage, Pure Desire)

Age and gender of person receiving treatment. (If couple or family, please include information for each person) *

Briefly state your reason for seeking counseling at this time. (Do not be specific) *

Payment for Services Payment for Services Private Pay- You are entitled to a Good Faith Estimate for private pay services provided by Grace River Christian Counseling. Private Insurance I will need a scholarship or fee reduction.

Insurance

If you have heard about a specific counselor and would like to schedule with them, please list their name:

How Did You Hear About Grace River?