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Help Request Form

This is a secure form. All data is encrypted for your protection.

This form is ONLY to request personal consultation
and formal counseling.


SUBMIT THIS HELP REQUEST FORM **ONCE ONLY**
For any additional communication after submitting
your Help Request, please use our SPCDC Contact Form.

Please do not submit prayer requests on this form.
If you have a prayer request please go to the Prayerbooks.

Please do not use this form to ask questions about spiritual warfare. Please post questions on our Q & A Forum.

SPECIAL NOTE: This form is to request assistance on spiritual matters. If you are in emotional crisis or suicidal and need someone to talk to please contact your local Crisis Center Hotline, or go to National Crisis Hotlines Index to find a National Hotline who can talk with you.

NOTE CONCERNING COSTS AND FEES: Our Counseling Services receives donations from the general public which allows us to offer our services FREE-OF-CHARGE to the client.

Our staff is available for limited travel for on-site investigations and counseling to the client's house or location or to provide intense on-site counseling. We may or may not, however, have the funds to allow for travel. If at the time funds are not available our staff may still travel if the client bears the burden of all out-of-pocket travel expenses (such as gasoline, air/bus/train fare, food and lodging). Thus, if we do not have travel funds available at the time, the only required cost to the client is out-of-pocket travel expenses.

Clients may, in some cases, arrange to travel to our offices at their own expense.

NOTE: At this time we do not have a bi-lingual or multi-lingual ability. Thus we are sorry for the inconvenience but to receive assistance from our agency you must be able to speak, read, and write English fluently and distinctly.

Due to excessive Long Distance charges to some countries, we can only accept clients from the Countries listed in the Country field. We can call cell phones only from the countries designated with an (m). For countries without an (m) we can only call landlines.

Clients outside of the countries listed in our form may still receive counseling if they are willing to pay for the phone call. This can mean 12 hours or more of long distance calls over a three month period. If a client wishes this option then choose "Other Country" from the Country list.

Or, we can also do counseling via Skype in those situations whereby phone communication is not possible or is cost prohibitive.

 

* Required Fields


SPECIAL NOTE

We cannot accept clients unless they have access to:

  1. a computer with a printer and Acrobat Reader Software (this software can be downloaded free from the Acrobat Website. More on this later)

  2. a valid email address

 


* Do you give your consent to record all voice communications between yourself and our agency staff?


Yes, I give consent
No,I do not give consent

If your answer is "No, I do not give consent", then we are sorry but for the reasons stated in the section above recording of voice communications is required. We thus cannot accept you as a client or speak with you by any voice communication device.

 

Recording Phone Calls:

MUST READ! It is our policy to record All voice communications (via telephone, voice chat, or Internet Phone) by cassette tape, electronic, or digital device. We do this for four reasons:

  1. Pastoral ... so that we can concentrate more on listening to you than in taking notes;

  2. Team Approach ...in order to provide you with the best and most professional services we never counsel in isolation. We use a team approach that allows us to better assess all aspects of your case so that we do not miss anything and are able to give your the best advice we can;

  3. Training ...to provide clinical examples for those we are training to be Deliverance Counselors; and

  4. Legal ...to protect you and us in the event any legal issues arise.

All records, files, notes, materials, and recordings are kept in strict confidence in accord with our Confidentiality Policy and that of professional ethics.


* What Country do you Live?



If you live in the US or Canada, what State or Province do you live?



If you live in a country not listed above, be sure to chose "Other Country" and then type which country you are from in the field below.


Other country:

Due to the excessive cost of Long Distance to some countries, we can only accept clients from the countries listed..

Clients MUST use a land-line phone unless there is a (m) next to the country, in which case we can call cell phones.

Clients must be able to read, write, and speak fluent and understandable English.

Appointment times are limited for those outside of North or South America due to time differences appointments:

  • For those in Western Europe and Western Africa the 2pm and maybe the 4pm time slots will work.

  • For Eastern Europe, Eastern Africa, and the Middle East the 2pm time slot is available.

  • For all points further east (India, China, Korea, Singapore, Indonesia, Japan, Australia, and New Zealand areas the only time that will work is the 8pm time slot.

Clients outside of the countries listed above may still receive counseling if they are willing to pay for the phone call. This can mean 12 hours or more of long distance calls over a three month period. Counseling via Skype is also an option.


* How long did you try the Self-Help advice on our Website before deciding to contact us?



This question refers to how long you tried our advice from our Self-Help page, not how long you tried to help yourself from other sources.

It is best to try our Self-Help advice for a period of at least two months before asking for Deliverance Counseling.

Click here to go to the Self-Help page.


* First Name:

 


* Last Name:

 


* Email:

 


* Phone Number:


* What type of phone is this number?
Regular Land-line
Cell Phone

 


If you have been a client of ours before, please indicate year?


 


* Birthdate:

We accept only clients who are 18 years of age or older


* Religous Affiliation?

If other, or for further description:

Select the Religious (or non-Religious) Group that most closely describes your own Faith Affiliation


* When are the best times to contact you?




Intake Interviews are by appointment only.
Appointments are only available in Afternoons and Evenings our time.

If no times are available you may be placed on a waiting list.


NOTE: We accept new clients only between September 15th and April 15th.

To check on time differences click here


* What time is it right now where you are?



This field helps us confirm your timezone.


Have you posted Questions about this Problem on our Q & A Forum?
If so, please list the date, subject, and name you posted under:


 


* Brief Description of Problem:


SUBMIT THIS HELP REQUEST FORM **ONCE ONLY**
If you have forgotten to include something on the forum, email us,
or discuss it with the Intake Counsellor on the phone.
UNDER NO CIRCUMSTANCES submit this form more than once.

This is a secure form. All data is encrypted for your protection.


Click on "Submit Request" ONCE ONLY