Counseling Application

    Please fill out the information on this form. All personal information will be held in the strictest of confidence.















    Personal Assessment

    Please answer all questions completely. If The Question does not apply, Write "N/A"










    What you Should know about Counseling

    This is what your Counselor can/will do:

    1. Work with individuals, groups and families to improve mental health

    2. Encourage clients to discuss emotions and experiences

    3. Examine issues including substance abuse, aging, bullying, anger management, careers, depression, relationships, LGBTQ issues, self-image, stress and suicide

    4. Help clients define goals, plan action and gain insight

    5. Develop therapeutic processes

    6. Refer clients to psychologists and other services

    7. Take a holistic (mind and body) approach to mental health care

    This is what your Counselor Will/Should Not do:

    1. Give advice that tells you what to do.

    2. Provide business consulting through the counseling venue.

    3. Exclude your past issues or overlook issues like depression, anxiety etc.

    4. Among other things, Your counselor is not your consultant or best friend. Although counselors are people you consult with on your strategies and goals, they are focused on your mental health. They are not to be your business consultant, organizational manager or financial advisor.

    5. Among other things, Your coach is not your consultant or best friend. Although life coaches are someone you consult about strategies and goals, they are life specialists not specific specialists like a business consultant, organizational manager or financial advisor. Your coach may specialize in these areas and you may be able to benefit from their expertise, but your coach is here to help you reach your goals, not give you data on how to grow, market or run your business.

      In the coaching relatioship, you will be invited to examine your life, past present and future. You should be aware that if any of the issues have sadness or difficult feelings and emotions attached to them in the normal course of your life, it is likely that these same feelings and emotions will emerge in a session. You must decide whether this is something you can handle at this time. Your willingness to experience these feelings and emotions honestly, and then let go of them, can open the way to a more joyful experience of living. The choice to do so, however, and the degree of your participation in the process, rests with you alone.

      The information requested here is meant to enable your counselor to better support you. It is not possible for A God Send to predict any experience. If during the course you find yourself feeling uncomfortable notify your counselor immediately.

      BY TYPING YOUR NAME IN THE BOX BELOW, you hereby acknowledge and attest that you have thoroughly and carefully read the information contained herein, that you understand it and agree to it, and that you have answered all questions truthfully.


    Financial Qualification

    Answer the following questions honestly and completely. Please be aware that this information is used by A God Send for purposes of verifying your eligibility for funded services.

    A God Send provides subsidized counseling when need is verified. In order to be approved, it is necessary to provide aggregate household income data, which illustrates financial need. This figure is to include all sources of income -- i.e. salary, child support, maintenance, investment income, housing allowances, etc.



    Rent or mortgage, Utilities (like electricity and gas), Internet/cable, Phone(s), Groceries and household supplies, Child care, Credit card payment(s), Car loan, Child support you pay, etc.


    In the above box, please provide the NAME, RELATIONSHIP, and PHONE NUMBER of TWO Emergency Contacts who your coach may contact in case of emergency.