Counseling Request Form

*= Required fields

Briefly describe what is it in your marriage, family or individual life that brings you to therapy*?

I would prefer a counselor that is:
Male   Female   No preference

Counselor preference (Each therapist schedules their own appointments and fee arrangements)
Richard Brandow
John Myers
Karen Goggans
Any


I would prefer a(n) ________ appointment:
Day   Evening   Saturday   No preference

How would you like for us to contact you?
Email    Phone

Additional comments:

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Your email will be forwarded to the appropriate therapist.

We will contact you soon,

Christian Family Services 913.383.3337