Start Your Intake Process Here

Thank you for joining the CHERISH program. Our counselors are trained, seasoned, vetted, and prepared to help you better understand and navigate seasons of life. You will receive a complete counseling experience, just as you would if you reached out to a counselor yourself and your relationship with your counselor will always remain confidential. This program will also include some surveys that will help us understand how we can improve and deploy this benefit broadly for the church.

Here’s what you can expect:

Sessions 1-3: no copay
Sessions 4-6: $60 per session copay
Click below to begin the intake process. After entering your contact information, a member of our team will contact you to help you choose the right counselor for you and complete your intake.
Complete a brief intake survey about your general health and demographics.

Important Notice:
GCN is an entirely online practice, and all counseling sessions are conducted through video communication. While our counselors are experienced in supporting a wide range of mental health and relationship concerns, please note that we are not equipped to provide ongoing care for individuals who are actively suicidal. If this situation arises during your treatment, we will work with you to transition to the appropriate level of support. However, we are unable to begin treatment for individuals who are actively suicidal.

By continuing with this form, you acknowledge that you have read and understood this notice.

This is a confidential message that goes directly to our intake team. We will make every effort to respond within 48 hours. If you do not receive a response in that time, please check your spam folder.

What is your name?

First Name

Last Name

Preferred Name or Nickname (if applicable):

What is your email address?

Phone

(###)

###

####

Current Residential Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you 18 or older?

Yes

What type of counseling are you seeking?

Individual Counseling (for yourself)

Couples Counseling

If you are seeking couples counseling, please provide the following details for your spouse:

Name Location (if different) Email

What brings you to counseling?

Please provide a brief description of the issues you're hoping to address

On a scale of 1-10, how would you rate your current level of emotional distress?

(1 = Minimal distress, 10 = Extreme distress)

Please provide more details about your emotional state:

Is there anything else you'd like us to know?

(For example: therapy preferences, previous mental health history, etc.)

What days and times are you generally available for counseling sessions?

(Please include preferred time zones.)

Have you previously worked with a GCN counselor? If yes, please include the counselor’s name:

Preferred Gender of Counselor?

Male

Female

No preference

If you have a certain counselor you would like to see, please list below. If not, we will offer some recommendations.

Current or most recent church you are/were attending?

Husband's name? (Teaching Elder in the PCA. Asked for program eligibility purposes)

How did you hear about GCN?

1. I understand that GCN is an out-of-network provider and does not file insurance claims on behalf of clients.
2. I acknowledge that many insurance policies offer coverage for out-of-network mental health services. It is my responsibility to verify with my insurance provider before beginning counseling.
3. I understand that if I wish to use out-of-network benefits, I must inform my intake coordinator before choosing a counselor.
4. I understand that GCN can provide documentation for insurance claims, but GCN cannot guarantee that my insurance will cover the cost of services.
5. I understand that I am financially responsible for the cost of counseling services in the event that insurance or financial assistance does not cover the full cost.

Yes

I want to receive updates and resources from GCN!

Yes, I do! As long as you don’t give it out to anyone else.

By submitting this form, I confirm that I understand and agree to the above points and am ready to begin counseling with GCN.