Start Your Intake Process Here

In service to our staff, CPC is committed to the whole person health of all our team members. As a result, we have partnered with Global Counseling Network to provide subsidized counseling sessions for all of our team members. GCN counselors are trained, seasoned, vetted, and prepared to help you better understand and navigate seasons of life. You will receive a complete counseling experience, just as you would if you reached out to a counselor yourself and your relationship with your counselor will always remain confidential.

The structure is as follows:

Sessions 1-4: $0 copay
Sessions 5-8: $65 copay per session
Sessions 9-12: $97.50 copay per session

Here’s what you can expect:

Fill out the form below to begin the intake process. After entering your contact information, one of our intake coordinators will contact you to help you choose the right counselor for you and complete your intake.
Complete a brief intake survey about your general health and demographics.
Begin your counseling!

This is a confidential message that goes directly to our intake team. We will make every effort to respond within 48 hours. If you do not receive a response in that time, please check your spam folder.

What is your name?

First Name

Last Name

Preferred Name or Nickname (if applicable):

What is your email address?

Phone

(###)

###

####

Current Residential Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you 18 or older?

Yes

What type of counseling are you seeking?

Individual Counseling (for yourself)

Couple or Family Counseling

If you are seeking couples or family counseling, please provide the following details for each participant:

Name(s) Relationship(s) to you Location (if different) Email(s)

What brings you to counseling?

Please provide a brief description of the issues you're hoping to address

On a scale of 1-10, how would you rate your current level of emotional distress?

(1 = Minimal distress, 10 = Extreme distress)

Please provide more details about your emotional state:

Is there anything else you'd like us to know?

(For example: therapy preferences, previous mental health history, etc.)

What days and times are you generally available for counseling sessions?

(Please include preferred time zones.)

Have you previously worked with a GCN counselor? If yes, please include the counselor’s name:

Preferred Gender of Counselor?

Male

Female

No preference

If you have a certain counselor you would like to see, please list below. If not, we will offer some recommendations.

Where are you employed?

How did you hear about GCN?

1. I understand that GCN is an out-of-network provider and does not file insurance claims on behalf of clients.
2. I acknowledge that many insurance policies offer coverage for out-of-network mental health services. It is my responsibility to verify with my insurance provider before beginning counseling.
3. I understand that if I wish to use out-of-network benefits, I must inform my intake coordinator before choosing a counselor.
4. I understand that GCN can provide documentation for insurance claims, but GCN cannot guarantee that my insurance will cover the cost of services.
5. I understand that I am financially responsible for the cost of counseling services in the event that insurance or financial assistance does not cover the full cost.

Yes

I want to receive updates and resources from GCN!

Yes, I do! As long as you don’t give it out to anyone else.

By submitting this form, I confirm that I understand and agree to the above points and am ready to begin counseling with GCN.