Ministries of Jesus - Counseling ICPF

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Counseling - Initial Contact Form

By filling out this form and submitting the information you agree you are ready to be placed on a reasonable waitlist to see a counselor. If you are not ready to sign up for counseling and just have some initial questions, please call 405-715-4851 for assistance.

Please select who is filling out this form?

If counselee is a minor, please fill in name, relationship to minor needing counseling, email and phone for the adult contact person.

First Name

Last Name

Phone Number

Mailing Address

Address Line 1

Address Line 2

City

State

Zip

Message

Marital Status
Married
Separated
Divorced
Widowed
Single

Age

Can you briefly explain what you are seeking counseling for?

The information collected in this next section is for demographic purposes only. Data collected is used to write grants which help fund counseling at Ministries of Jesus.

Ethnicity
Black or African American
Latino or Hispanic
White or Caucasian
Asian
Other

Primary Spoken Language
English
Spanish
Other

Are you a U.S. Veteran?
Yes
No

Religious Peference
Catholic
Muslim
Buddhist
Agnostic
Christian
Other

When was your most recent mental health evaluation or counseling session?

Are you currently taking any medication for anxiety, dpression, or other mental illnesses? If so, please list name(s) and dosage. If none, write "none."

Do you suffer with drug addiction?
Yes
No

Do you suffer with alcoholism?
Yes
No

Are you currently in danger of harming yourself?
Yes
No

Are you currenlty in danger of harming anyone else?
Yes
No

Please understand, the more flexible you are on time availability, the sooner you will be able to be scheduled with a counselor.

Please list below what day(s) and time(s) would work best for you to see a counselor. Availability must be Monday - Thursday between 9am - 4pm.

Do you prefer a male or female counselor?
Male
Female
Either is fine

Are you willing to see a Counseling Intern?
Yes
No

Submit