The Balm of Gilead Counseling Request Form

The Balm of Gilead Counseling Request Form

Please fill out the counseling form below so that we are better able to assess your needs. Once we receive and review it, you will be contacted by a counselor that best serves your needs to schedule an appointment. We will make every effort to accommodate your schedule. However, please understand that our counseling services are in high demand, and we may not be able to fit your schedule. Some flexibility will be helpful. The Balm of Gilead operates on a sliding scale donation basis ranging from $40 to $100 for individual counseling, and $50 to $100 for premarital and couples counseling. We do not accept insurance. We are looking forward to meeting you and are covering you in prayer. God bless.

First Name*

Last Name*

What Is Your Age?*

Address*

City*

State*

Zip Code*

Phone:*

Email:*

How did you hear about us?*

Why are you seeking counseling?*

Explain Your History with Drugs & Alcohol*

What Do You Expect To Get From Counseling?*

Are You Currently Under A Physician's Care?*

List Any Medications You Are Currently Taking*

List Any Other Pertinent Information That Will Help Us Assess Your Needs*

Days Available for Counseling*

Times Available for Counseling*

Able To Fill Out Financial Application On Request?*

Select or enter value

Suggested Sliding Scale for Individual Counseling*

Less than $50,000 annually $40.00

$50,000 to $75,000 annually $55.00

$75,000 to $100,00 annually $75.00

Over $100,00 annually $100.00

Suggested Sliding Scale for Premarital & Couples Counseling

If you are requesting couples counseling, please select the amount you can afford per session according to your personal income alone or combined with a spouse/partner/fiance. Skip if you are only seeking individual counseling.

Less than $50,000 annually $50

$50,000 to $75,000 annually $65.00

$75,000 to $100,000 annually $85.00

$100,00 and over annually $100.00

Form Date Field*

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