Please print out and send completed form to Lighthouse in Scranton Inc. P.O. Box 199 Scranton, PA 18504
Application for Pastoral Counseling
- First and last name.
- Mailing address.
- Home and work phone number.
- Reason for desiring counseling.
- Medications: types and dosages.
- Past forms of therapy/counseling, and reasons for therapeutic or counseling visits in the past or at present.
- History or diagnosis of mental illness.
- History of addictions.
- If suffering from an addiction, list time in sobriety; weeks, months, years, days.