Counseling Support Form – Dakota Baptist Convention

* Please note that these funds are only available to members of the Dakota Baptist Convention.
Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Is this an emergency?*
- Yes
- No
Do you have a counselor already identified?*
- Yes
- No
Would you like to be referred to a counselor that is provided on a confidential basis by the DBC?*
- Yes
- No
Please read and check that you have read and agree to the following:*
- I understand that if I use a counselor provided by the DBC, the counselor will contact me to begin a counseling relationship.
- I understand that if I use a counselor of my preference, I will submit an invoice for the counselor to be paid to myself for reimbursement.
Please note that all inquiries into counseling will be held in strictest confidence by DBC staff and counselor.
- A confirmation email will not be sent to you due to the sensitive nature of this form unless you check this box.
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