Counseling Request - Refuge.Church

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To request professional counseling from Licensed Mental Health Counselor, Karen Culbertson (Lic. # MH16543), please complete the form below.

Name(required)

Email(required)

Phone(required)

How did you hear about Karen?(required)

Who referred you to Karen?

Marital Status(required)

What are your main areas of concern? (required)

Have you had prior counseling, and if so, was it helpful? (required)

What do you hope to achieve through counseling? (required)

Any other information that would be helpful to know?

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