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Request a Service

Our Session Availability is 8:30AM-4:30PM Monday, Tuesday, Thursday and Friday. We are closed Wednesday, and Saturday is by appointment only. We are also available for emergency sessions such as holiday appointments.

Please fill out the form below to start your sessions. We will call you to schedule an appointment

Which Service are you Requesting?

Individual($100)

Couples($120)

Mental Health($100)

First name*

Last name*

Occupation

Street Address*

Address Line 2(optional)

City or Town*

State*

Zipcode*

Phone*

Birthday

Month

Day

Year

Email

Referred By

Phone of Refferral

Do you have a sponsor for your sessions? Include the name of any church, organization or individual who is sponsoring your visits

Phone of Sponsor

Emergency Contact

Contact Name and Relation

Status

Spouse First, Last Name and Age

Children

Children's First, Last Name(s)

Education(All That Apply)

High School

Some College

Associate's

Bachelor's

Grad School

How Well Did You Do(Education)?

Religion/Faith

Health*

Excellent

Good

Average

Poor

Concerning

Describe any physical problems you currently have or have had within the past 10 years

Are you currently under doctor's care?

Yes

No

If yes, please describe your care

Physician Name

Address

Phone

Are you on currently on any medications or other unprescribed substances?

Yes

No

What are they?

How long have you been on them?

Please describe any alcoholic beverages you consume

How often do you consume alcohol?

Have you previously had counseling?

Yes

No

When?

Where?

With Whom?

For How Long?

Why did you stop?

In your own words, please briefly describe the main issue that prompted you to seek counseling at this time

How long have you faced these problems?

Has the problem gotten better or worse?

Better

Worse

When did these problems begin?

If the problem has gotten better, what do you think helped and why?

If the problem has gotten worse, what do you believe caused the problem to worsen?

Is there a time when you felt comfort or just held steady and why?

Are there others who you believe are contributing to your problem, why or why not?

Do you currently have spiritual help, Church, pastor, group, or other? Please explain in detail

Do you currently have a daily relationship with Jesus, and would you like to?

207-944-0005

savinggracecounseling@outlook.com

700 Main Street Suite 3

Bangor, ME 04401

Mission Satement

Vision Statement

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