ICPC Counseling Intake

First Name

Last Name

Birthdate

Gender

Phone Number

What type of counseling are you seeking?

For spiritual counseling, please select your preference:

Please provide a general description of your concern

Have you been to ICPC before?

Have you previously seen a professional counselor?

What are you struggling with mostly?

By utilizing the services of ICPC, you agree to hold ICPC harmless, indemnify and release ICPC or any of its affiliated or partners from all causes of action, allegations, lawsuits, claims, damages or demands whatsoever, in law or equity, that may arise.

Contact Information