Christian Talk Therapy

The Lord God hath given me the tongue of the learned,

that I should know how to speak

a word in season to him that is weary.

Isaiah 50:4

Christian Talk Therapy
2449 Golf Road
Suite 1
Philadelphia, PA 19131
ph: 215-375-7879
therapist@christiantalktherapy.com

Initial Intake Form

Please Read our

Counseling Disclosure Statement

Before engaging in therapy, we require that you read and accept our Counseling Disclosure Statement.

Click Here to review the form and once you have read it, please type "Yes" at the first area on the right. If you have questions, please send an e-mail from the "Contact Us" page.

Suicide/Homicide Alert

If you are having thoughts of hurting yourself or someone else, for your safety, we advise you to go to the nearest hospital Emergency Room, immediately or dial 9-1-1 for help.

*If you have read and accept the Counseling Disclosure Statement, please type "Yes" below.

*First Name:

*Name:

*Email:

*Contact Number:

Please provide the best number to reach you.

Contact Preference:

City

This information is needed to determine whether there is a difference in Time Zones.

*State/Province:

*Country:

Church you attend:

Type of Service Requested:

Please indicate the type of Counseling you are seeking--Individual, Couples/Marriage, or Pre-Marital

Reasons for seeking therapy:

Please indicate what has led you to seek therapy at this time.

Are you currently under a Doctor's Care? If so, list the reasons.

Are you taking medication? If so, please list below.

*Are you thinking of hurting or killing yourself or someone else?

Join Mailing List?

Please add me to your mailing list.

Submit Your Message:

Once you have submitted your form, you are ready for your Initial Consultation! You will be contacted via e-mail to set up your appointment within 48 hours (excluding Sunday).

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Christian Talk Therapy
2449 Golf Road
Suite 1
Philadelphia, PA 19131
ph: 215-375-7879
therapist@christiantalktherapy.com