Intake Form

Name*
First Last
Email*
Phone*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What days and times are you regularly available for appointments?*
Would you prefer an appointment with a single or married male or female? If you do not have a preference please answer 'no preference.*
Are you applying for counseling through the Cherish or ServantCare program?*
- Yes
- No
At this time, the CCEF main office does not work with third-party insurers nor provide the diagnostic codes needed for reimbursement. All counseling charges are due prior to each appointment.
Name
This field is for validation purposes and should be left unchanged.

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