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First Name *

Last Name *

Email *

Phone *

Who are you seeking counseling for? *

Select preferred location *

Choose your state

Would you prefer a male or female counselor?

How would you like to meet with your counselor?

Do you know which counselor you'd like to work with?

Are you or the client(s) covered by Medicaid, CHP+ or a Medicare Disability plan? *

We do accept some Medicaid plans, but will need to verify benefits. At this time, we do not accept any other insurance plans.

Medicaid ID Number

Date of Birth

How can we help? *

How did you hear about us? *

How would you like to be contacted? *

Text

Phone Call

*You will also receive a confirmation email upon submitting this form, and a confirmation text if you opt in to text messages.

Do you consent to receiving text messages from Cornerstone Christian Counseling? *

Yes

*By checking YES, you are consenting to be contacted by SMS text message and agreeing to our Privacy Policy (https://christiancounselingco.com/privacy-policy). Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.

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