Christian Counseling

Lake City, FL

Rebekah Prewitt, MA
(407) 731-9998
rp@lakecitycounsel.com

Questionnaire

Please fill the form out completely. If something does not apply, write, N/A.


Name (First and Last):

Phone Number:

Email Address:


Date of Birth (month/day/year):

Gender: Male Female

Briefly answer the following questions.

1. What is your problem?


2. What have you done about it?



What is your religion?

Do you belong to any clubs or organizations? Yes No

List the name(s) of the organizations:

Referred by (internet, newspaper, minister, friend, spouse, other, etc.):