Counseling Request Form

Please provide the following information to help our team get you connected with CCM. All information provide is confidential.

Your name *

Last name

Email address *

Phone number *

Phone type

Address

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

What kind of counseling are you seeking? *

For myself

For my child

For my marriage

For Pre-Martial Counseling

Other

What is the birthdate(s) of the person needing counseling? *

How are you connected to City Life Philly? *

Choose the best option that describes your engagement.

Regular Attender- Been attending for more than 3 months online or in person

Dream Team- Part of City Life's Serving Team

Online Attender- I have never attended in person

Guest- I have been attending for less than 3 months

Other

Briefly describe why are you seeking counseling. *

What form of counseling would you prefer? *

In-Person

Virtual

No Preference

Do you prefer a male or female counselor? *

Male

Female

No Preference

How do you plan to pay for counseling? *

City Life receives special prices for individuals of $135 for Initial session and $90 for following sessions. Couple/Family counseling is $165 for Initial session and $135 for couples following sessions and $150 for family following sessions.

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City Life Church
admin@citylifephilly.com
(215) 462-0300

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