Client Portal - Mount Olivet Counseling Service

We are so glad you've decided to reach out to us for support. This form is just for NEW clients to get started with us. If you are a returning client, please contact us directly at 612.927.7335 or mpach@mtolivetcounseling.org.

Please provide the information below to get started with your intake. Counseling session fees are only $65 for members of Mount Olivet Lutheran Church and just $135.00 for non-members.

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

Mount Olivet Counseling is not a crisis center. If this is a mental health crisis, please dial 988. If this is a life threatening emergency, call 911 or go to your nearest emergency room.

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We are so glad you've decided to reach out to us for support. This form is just for NEW clients to get started with us. If you are a returning client, please contact us directly at 612.927.7335 or mpach@mtolivetcounseling.org.

Personal Information

Contact Information

Phone

Address

Provider:

Please explain the reason you are seeking help at this time: