Counseling Recommendation Form

DISCLAIMER

The Lane of Roses Team wants to engage with you, empower you, and equip you to live out your God-given purpose! We want to provide you with as many resources as we can. We are not licensed or registered mental or medical healthcare providers.

The content, resources, and services that we provide on our website, blog, Instagram, Facebook page, Pinterest, and all other mediums are not substitutes for the knowledge, skill, and judgment of qualified psychiatrists, psychologists, physicians, or other health care professionals. Always seek the advice of your qualified healthcare provider with any questions you may have regarding a medical condition. We cannot prevent, diagnose, or treat conditions or ailments of any kind. However, we would love to help connect you to any of the above mentioned mental or medical healthcare providers!

When utilizing any of our resources, you acknowledge that you are doing so voluntarily and that you alone are responsible for choices and results that come from the use of our content, resources, or services. Additionally, you accept full responsibility for anything you choose to use or participate in currently and in the future. Lastly, you agree that any results that come from using information and/or services provided by Lane of Roses cannot be guaranteed, and depend on your efforts, intentions, actions, and God’s work in you and through you.

If you are in crisis or you think you may have an emergency, call your doctor or 911 immediately.

If you’re having suicidal thoughts, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or at 988 to talk to a skilled and trained counselor at a crisis center in your area at any time.

Counseling Inquiry Form

First Name

Are you over the age 18?

YES

Last Name

How old are you?

City

State

Zipcode

Phone Number

Birthday (M/D/Y)

Are you wanting to do in person counseling or e-counseling?

In-person

Online

Open to either

When you think about counseling, what are you hoping to get out of it?

Do you have any concerns about counseling or is there anything you think would be important for us to know?

What is your budget for counseling per session?

Have you ever been to counseling before? If so, please list the name(s) of the counselor(s) you've seen previously.

I understand and agree that receiving counseling recommendations through Lane of Roses is merely a tool for me to help narrow down the search for a counselor in my area.

I understand and agree that Lane of Roses cannot call and make appointments with a counselor on my behalf. I assume full responsibility for setting up an appointment with the counselor I choose.

I understand and agree that Lane of Roses is released from the responsibility of the outcome of my counseling.

I authorize that all of the above information is true. And I authorize Lane of Roses to recommend counselors in my area. I agree that by typing in my first and Last name that it represents my signature.

Thank you for submitting the care form! You will be contacted shortly. If this is an emergency or you are having thoughts of suicide please call 911 or the suicide hotline at 1-800-273-TALK (8255).

Counseling Inquiry Form

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