Counseling Services Nancy K. Vermeersch, LISW

Licensed Counselor/Therapist

Phone: 319-550-1621
Text: 319-343-6371
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Counseling Forms

Please complete ALL of the following forms and bring them with you to your first session. This will save time and allow us to begin our conversations right when your session begins. If you have any questions about the forms, please contact me.

  • Client Information Sheet-Please complete
  • Degrees and Credentials-Please complete
  • Fee Schedule-Please complete
  • Notice of Privacy Practices , (this is a copy for your records)
  • Privacy Notice Receipt Form-Please complete
  • Caffeine Questionnaire
  • Depression Inventory

Are you ready for a change? Reach out today.

Phone:
319-550-1621

Text:
319-343-6371
Cell (Emergencies Only):
319-389-9424

Email:
nancy@crchristiancounseling.com

Address:
4403 1st Avenue SE, Suite 215
Cedar Rapids, Iowa 52402