Interest Form Interested in receiving services? Fill out some info and we will be in touch shortly! Name * First Name Last Name Age * Email * Phone * (###) ### #### How did you hear about us? * I Attend Life Pointe or Eastside Church A Friend or Leader Referred Me I Found you online Other Counseling Options * Individual Couples Family Additional Notes or Requests Thank you for your interest in our counseling ministry! Please note that this form is an initial contact request is the initial step of contact and does not serve as an application for counseling. We receive many requests and are committed to getting back to you within 2-3 business days.