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Marriage Counseling Request Form
*All information submitted will remain confidential.
Your Name
*
First Name
Last Name
Spouse Name
*
First Name
Last Name
Current Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Employer/Occupation
Education (Level, School, Major)
Are you a member of Grace Church?
*
Humble
Tomball
Liberty
Grace En Español
Online
Not a Member
If you are a member, how long have you attended?
What has been your involvement at Grace Church?
Women of Grace
Men of Grace
Life Groups
Oneteam
Other
How many years have you been married?
*
Have you been married previously?
*
Please Select
Yes
No
Do you have any children from a previous marriage or relationship?
*
Please Select
Yes
No
Do you have any children with your current spouse?
*
Please Select
Yes
No
Please list ages of children
*
Are you a Born-Again Christian?
*
Please Select
Yes
No
Please give detailed description of why you are seeking counseling?
*
How long has this issue existed?
*
Have you spoken to anyone at Grace Church, or to anyone else?
*
Are you currently seeing, or have you seen, a counselor about this?
*
Please Select
Yes
No
If you have seen a counselor, but not for the same reason, then why?
*
What results are you expecting from counseling?
*
Member Photo
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