Language
English (US)
Español
Individual Counseling Request Form
*All information submitted will remain confidential.
Name
*
First Name
Last Name
Gender
*
Male
Female
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.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Employer/Occupation
Education (Level, School, Major)
What is your personal status?
*
Single
Engaged
Married
Separated
Divorced
Widowed
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
If you have been attending another church, where have you been attending? What has been your involvement there?
Are you a Born-Again Christian?
*
Please Select
Yes
No
Please check the appropriate boxes for the type of counseling needed
*
Anger Issues
Financial
Depression
Divorce Recovery
Spiritual
Grief
Marriage/Family
Sexual Addiction/Pornography
Chemical Dependency
Abuse
Other
If other, please explain
Please give a detailed description of why you are seeking counseling
How long has this issue existed?
How has this issue affected you?
Have you spoken with anyone in Grace Church leadership?
What results are you expecting from counseling?
Member Photo
Browse Files
To better serve you, would you please be so kind to upload a photo of yourself to attach with your submission? Every ONE matters and you certainly matter to us! Having a picture will help us remember those we've served and those we may serve again in the future.
Cancel
of
Submit
Should be Empty: