General questions: Voicemail / text messaage 314-994-9344, or email helpdesk@agapeccs.com. Messages are returned between 9am - 5pm, Mon - Fri.

WELCOME!

To submit an inquiry about our services, or to become a new client, please complete and submit your information below.

**PLEASE NOTE: We currently have a wait list, which may be anywhere from a couple weeks to a couple months, depending on needs and availability. Once you've submitted your information below, we will add you to our wait list and have a provider reach out to you for scheduling, as soon as there is an opening for you.**

Contact / Inquiry Form

Please choose a request type below

Your email address

Your First Name

Your Last Name

I am seeking counseling for...

IMPORTANT:

Due to legal constraints, if you are inquiring on behalf of someone else, who is over 18 years of age and is a legal adult, they MUST complete this form themselves. We will NOT be able to accept an intake that was completed by another person. Thank you for your understanding.

IMPORTANT:

Due to legal constraints, only a LEGAL GUARDIAN can complete this form on behalf of a child. We will NOT be able to accept an intake completed by someone who is not a legal guardian of the child. Thank you for your understanding.

Your Date of Birth

(mm/DD/YYYY format)

Child's name (full legal name / spelling)(optional)

How old is your child?(optional)

Child's Date of Birth

(MM/DD/YYYY format)

Significant Other or Family Member's Name

Please confirm your phone number

(use format: ### - ### - ####)

Is it okay for us to leave a vm at the phone number provided?

Preferred Method of Contact

Select all that apply. (By providing your phone number and selecting "text message" as a preferred method of contact, you are agreeing to receive text messages from Agape Christian Counseling Services. Please note that message and data rates may apply, and the frequency of messages can vary.)

Mailing Address

City

State

Other:

Please state your country and state/province

Zip Code

Referral Source (how did you hear about Agape?)

Please list the name of the church / pastor who referred you:(optional)

Please list the name of the counselor / counseling facility who referred you:(optional)

Please list the name of the doctor who referred you:(optional)

Please list the name of the friend / family member who referred you:(optional)

Please list which radio station:(optional)

Please list the name of the lawyer who referred you:(optional)

Please list the name of the client who referred you:(optional)

Please list the name of the school / teacher who referred you:(optional)

Referral Source - Other:(optional)

Have you previously seen a counselor at Agape?

Name of Previous Counselor(optional)

Do you have a preference of the gender of your counselor?

Would you like to request a particular counselor(s)?

Please enter the name(s) of the counselor(s) you are requesting:(optional)

Are you looking for in-person or telehealth (video chat) services?

What is your scheduling availability for appointments?

(select all that apply)

Have you (or the client) experienced any thoughts of suicide or self-harm within the past 7 days?

By checking the box, I acknowledge and understand that this is not an emergency service and it may take up to 48 hours before a representative of this agency can respond to my request.

IMPORTANT: If you are experiencing an emergency please call 911 or go to the nearest emergency room.

Do you have insurance?

Gross Annual Household Income

to determine your fee, using our Sliding Scale

Number of people in your household

to determine your fee, using our Sliding Scale

For expedited service, upload a copy of your insurance card (front & back). You can add an attachment at the bottom of this ticket.(optional)

(check box, when complete)

Name of Insurance Company

Name of Primary Care Physician

(required if insurance is Tricare or UMR)

Name of Insurance Company - Other(optional)

Insurance Member ID(optional)

Payer ID or Issuer #

(if your insurance card doesn’t have one, enter 0)

Primary Cardholder on Policy

(please use legal name/spelling as appears on insurance card)

Primary cardholder's relationship to client

Primary Cardholder's Date of Birth

(MM/DD/YYYY format)

Primary Cardholder's Address

Primary Cardholder's Address (Line 1)

Primary Cardholder's City, State, Zip Code

Do you plan to use EAP (employee assistance program)?

Name of Your Employer

Name of EAP Company(optional)

Name of EAP - Other(optional)

EAP Authorization Code

Number of EAP Sessions Authorized

Reason for Seeking Services

Please provide brief description of why you are seeking counseling services.

Message / Additional Details

Attachments(optional)

Add file or drop files here