1. Client Name
*
First Name
Last Name
2. Is the client a minor?
*
If yes, then input the adult contact's information below (NOT the minor client's email/phone).
3. Contact Name
First Name
Last Name
4. Client/Contact Email
*
5. Client/Contact Phone
*
Country
(###)
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7. If you requested a joint/couples session in the question above, who would you like to attend sessions with? (Please provide their full name, phone number, and email.)
8. Current Availability (PST)
*
Please tell us the days and times you're available for a session. The wider your availability, the more options we have to match you with.
9. What are your goals for this next session? What outcome(s) are you hoping to experience?
*
10. Why do you want to switch to a new minister/service?
*
11. What are you looking for in a new minister?
*
12. Do you want a video or in-person session?
*
Video session
In-person session
Either video or in-person is fine
13. What's your top priority when we assign you to one of our team members?
*
Appointment location preference (in person vs virtual)
Seeing the minister I mentioned above (I'll adjust my schedule if needed)
My availability
Soonest available appointment (I'll adjust my schedule if needed)
Whichever minister you think is the best fit for me (I'll adjust my schedule if needed)
My requested service
14. What's your second priority when we assign you to one of our team members?
*
Appointment location preference (in person vs virtual)
Seeing the minister I mentioned above (I'll adjust my schedule if needed)
My availability
Soonest available appointment (I'll adjust my schedule if needed)
Whichever minister you think is the best fit for me (I'll adjust my schedule if needed)
My requested service
15. We periodically update our policies and want to make sure you have our latest information. How will you access and review our most updated policies?
*
I will review the extensive policies on tcbethel.com/disclosures
I'd like a copy of the summarized policies.
16. Is your credit card on file up to date?
*
Yes, my credit card on file is still good/correct.
No, please send me a new credit card form.
I believe it's still good, but I'm not 100% sure. I'll log in to my Client Portal to confirm/update my account as needed. (Please contact the TC office if you need assistance.)
18. Is your contact information on file (home address, phone number, email address) correct?
*
Yes, what I submitted previously is correct.
No (or I'm not sure), so I'm listing my updated information below.
19. Updated Home Address (if applicable):
20. Updated Email Address (if applicable):
21. Updated Phone Number (if applicable):
Country
(###)
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