What is your name? *

First Name

Last Name

Phone

(###)

###

####

Current Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you 18 or older? *

Yes

No

What type of counseling are you seeking? *

Individual Counseling (for yourself)

Couple or Family Counseling

Counseling for a minor

Preferred Gender of Counselor? *

Male

Female

No preference

Are you currently a full time or part time ministry staff member at a North West Baptist church?

(Select all that apply)

Yes

No

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.