Restore Counselling Request

Your name *

Email address *

Phone number *

Gender

Birthdate *

Marital status *

Are you a member of TLC? *

Do you attend regularly? *

Have you attended Connect (TLC Membership Class)? *

Do you belong to a small group (Cluster)? *

Cluster Venue & Leader *

Please describe the main reason you are seeking counselling or help / the issues you would like to address or work on. *

What is your hope/goal for counselling or help? *

Have you had previous counselling concerning the issues for which you are currently seeking counselling or help? *

If yes, please give details – name of counsellor/ organization, duration of counselling and outcome. *

If you are seeking couples counselling, both partners are required to complete this form individually

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