Counseling Center Appointment Request

After you submit your request, we will contact you with an appointment time to work with your schedule.

Your name *

Email address *

Phone number *

Select a therapist from the dropdown list below.

Have you ever been seen by one of our counselors? *

Yes

If yes, which counselor did you see?

Were you referred to our counseling center by anyone? *

Yes

If yes, by whom were you referred?

Have you completed the Discover Broadmoor class? *

Yes

If you are not a member of Broadmoor Baptist Church, our full time counselors have a sliding income fee scale. What is your yearly income to base your fee upon?

Are you active military? *

Is this appointment for a child under the age of 18?

yes

What is the name and age of your child under the age of 18?

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