Counselor Referral Form

Thank you for your interest in being included on the LJCC counselor referral list. We do limit the number of counselors listed based on areas of specialty. LJCC requests that all counselors belong to AACC, American Association of Christian Counselors and appreciate your willingness to offer an occasional class to members of our congregation where appropriate. For consideration please click on the link and complete the form below.

 

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Contact Information

First Name:

Last Name:

Business Name:

Email:

Phone Number:

(  )  -   ext:

How would you prefer to be contacted?

By Email By Phone

Website:

Are you an AACC Member?

Yes No

Address

Street 1:

Street 2:

City:

State:

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Zip Code: