Rising Star Baptist Church

Counseling Intake Form

Personal Informationpage 1 of 2
Please complete the questions below. Once you have completed this form and turned it into our office, you will be contacted within 48 hours (excluding weekends and holidays) by our Peer Counseling Coordinator to schedule an appointment with a counselor. *required fields



First Name Last Name
Phone Number
Select one
YES
NO
Select all that apply
Morning
Afternoon
Evening
Email Address

Select one
Male
Female
Select one
YES
NO
* required