Marriage Counseling Request Form
*All information submitted will remain confidential.
Name
*
First Name
Last Name
Spouse's Name
*
First Name
Last Name
Current Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Phone Number
*
-
Area Code
Phone Number
Age
*
Email
*
example@example.com
Employer/Occupation
Education (Level, School, Major)
Are you a member of Grace Church?
*
Humble
Tomball
Garden Oaks
Liberty
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
OASIS
Connect Groups
Serve Team
Grace Marriage & Family
Other
If you have been attending another church, where have you been attending? What has been your involvement?
How many years have you been married?
*
Have you been married previously?
*
Yes
No
If previously married, how many years?
Please give important information about why the marriage ended.
Do you have any children from a previous marriage or relationship?
*
Yes
No
Please list ages of children.
Do you have any children with your current spouse?
*
Yes
No
Please list ages of children.
Briefly describe your relationship with Jesus Christ.
*
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?
*
Please type your name as a signature.
*
Enter the message as it's shown
*
Submit
Should be Empty: