Please complete the following questions to be matched with a counselor.

Membership & Payment Option
Please select one that is applicable*

Yes, I'm an official member of an LCN church and will receive financial assistance. ($50 subsidy by the network, $50 out of pocket fee, up to 10 sessions per year)No, I'm not an official member of an LCN church and will pay the fees agreed upon with the referred counselor or counseling center (insurance may or may not be considered)
If you are not an official member of an LCN church, please provide the name of your church:*
Please note that this is strictly a referral to independent counselors and/or counseling centers, and there is no guarantee that you will be matched with a LCN networked counselor.
If you are an official member of an LCN network church, you may reapply every year to receive additional 10 sessions at the fixed lowered rate and the subsidy support. This renewal begins at the beginning of the year in January.
Late cancellation fee: If you cancel the scheduled appointment less than 24 hours notice, you will be responsible for a $50 fee.

Additional Information
Applying for a minor: If you are a minor (under the age 18) or you are applying on behalf of a minor, please provide a guardian's name and relationship to the applicant.
Name

First NameLast Name
Relationship
Is the applicant a pastor or a pastor's immediate family member?

YesNo
If yes, please explain what official role you or your immediate family member has, along with the church name.
Is the applicant informed and willing to receive counseling?

YesNo

Additional Information
Have you used LCN services before, and are you reapplying?

YesNo
If yes, please let us know if you want to connect with the same counselor, along with the counselor's name. (We cannot guarantee that you will be reconnected with the same counselor, but we will try.)
If you do not contact your LCN counselor within two weeks of being matched, we cannot guarantee that the same counselor will be available for you.

Thank you.
Should be Empty:

Personal Information