Pastoral Counseling Registration Form

Pastoral Counseling Registration FormThank you for your interest in pastoral counseling through Bethel New England. Please complete the form below to register for counseling services. Once the form has been submitted you will be contacted by our counselors within 1-3 business days.
Please note, we are not a crisis center and are not available for crisis support services. If you have immediate concerns related to safety please call 911 or contact Connecticut Mental Health Center (CMHC) Crisis Service at (203) 974-7300 for adults, for anyone under 18 please call 211.

First and Last name*
Age*
Gender at birth*
Email*
Phone Number*
Reason you are seeking counseling?
Reason you are seeking counseling specifically at Bethel New England?
What is(are) your goal(s)
Do you attend Bethel New England?
If not, do you attend church elsewhere?
Are you currently under professional care for your mental health? (e.g. clinical counselor, psychiatrist, medication provided by a doctor). If "yes", provide a brief explanation.
Have you ever been under professional care for your mental health? If “yes”, provide a brief explanation.
Are you looking for help regarding suicidal thoughts, homicidal thoughts or self-harm?
Are you under the age of 18 or are you seeking help for someone who is?
Thank you! Your submission has been received!
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Thanks for signing up!
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