Intake Form

We have been made aware of an ongoing issue with the submission of a few intake forms. If you have recently submitted an intake form and have not had anyone contact you within 48 hours, please send an email to [email protected]. We apologize if this has affected you; we are actively working to update our system.

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 a participating member of ServantCare or Cherish?*
- 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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Intake Form

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.

About CCEF

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.

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About CCEF