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Faithful Surrender Counseling

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Scheduling Request

First name*

Last name*

Email*

Confirm your email address*

Phone*

Birthday*

Month

Day

Year

Address*

Do you prefer a follow-up phone call or an email?*

What type of therapy are you interested in? (e.g. Individual, Couples, Family) Please specify if other(s) will be joining you in session.*

What is the primary reason you are reaching out?*

Tell me more about what brings you in*

E.g. Do you have any insight into what's going on, what is your experience, what makes it better/worse, etc.

When did this concern first start?*

What, if anything, have you previously tried to address your concern(s)?*

Is there anything else I should know?

How did you hear about Faithful Surrender Counseling?*

Faithful Surrender YouTube Channel

1100 Highland Avenue, Conway, PA, 15027

Located in the Friendship House across from Conway Alliance Church.

Faithful Surrender Facebook Page

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