Counseling Interest Form

Your name *

Last name

Email address *

Primary campus *

Gender *

Phone number *

Phone type

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

What type of support are you looking for? *

What are your primary concerns for seeking counseling? *

Depression

Anxiety

Grief

Anger

Shame

Lack of purpose and motivation

Unwanted Behaviors

Relationship challenges w/ family of origin

Relationship challenges w/ a romantic partner

Challenges related to faith

Other

Do you regularly attend TDC? *

Are you part of the leadership community at TDC? *

Are you member of a partnering organization?

DC127

Cornerstone School

Little Lights

Other

Do you have a special request or preference for a counselor? Please let us know.

Please meet our team: https://districtchurch.org/about/#counseling

Do you need financial support for counseling? *

Are you currently in danger or at risk of immediate harm to yourself or others? *

Please understand that our counseling ministry does not have adequate resources to provide effective services in case of crisis and emergencies, including but not limited to, current suicidal/homicidal ideation, active cases of abuse and neglect, current episodes of substance abuse and self-harming behaviors, and other situations that require immediate medical and clinical intervention. Therefore, if you need emergency services, please immediately call 911 or go to the nearest ER. We are also happy to find the right support in the area.

By answering "yes," you acknowledge that IF you need the emergency and/or protective services now OR in the future, you will immediately contact the appropriate service providers (911 and local emergency resources) to receive the support. *

Please understand that neither The District Church counseling ministry nor our independent contractor counselors are equipped to provide any emergency or protective services.

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The District Church
info@districtchurch.org
(202) 558-9745