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Counseling Interest
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Counseling Interest
Error
Work Entry
Added: 2/16/2026
First Name
First Name cannot contain special characters such as quotes, parentheses, etc.
First Name cannot contain emojis or special fonts.
First Name is required.
Last Name
Last Name cannot contain special characters such as quotes, parentheses, etc.
Last Name cannot contain emojis or special fonts.
Last Name is required.
Email
Email address is not valid
Email is required.
Mobile Phone
Mobile Phone is required.
Give your consent to receive SMS messages by simply checking the box.
Membership Status
Member - I am a current member of RBC or in the process
Non-Member - I currently attend RBC regularly
Non-Member - I do not regularly attend RBC
Membership Status is required.
Have you previously received care and counsel from a pastor, counselor, or mentor, or are you currently receiving care?
No
Yes
Have you previously received care and counsel from a pastor, counselor, or mentor, or are you currently receiving care? is required.
Please provide the name of the pastor, counselor, or mentor:
Please provide the name of the pastor, counselor, or mentor: is required.
Do you understand the need for further assessment, and that you will be sent additional forms for completion before scheduling can occur?
No
Yes
Do you understand the need for further assessment, and that you will be sent additional forms for completion before scheduling can occur? is required.
Submit