Counseling Referral Request

  • Counseling Referral Request

    BF Care Network

  • Directions:

    "Primary" indicates the person requesting a counseling referral. "Secondary" indicates Spouse/Significant Other/Child/Family Member also included in counseling referral request.

  • PRIMARY INFORMATION

  • Today's Date*
     / /
  • Gender*
  •  - -

  • SECONDARY INFORMATION

    Child or Dependent
  • Gender
  • Birthday (Secondary)
     / /
  •  - -

  • Church Engagement

  • Indicate your level of engagement at Brazos Fellowship:

  • If you attend our church, how often each month do you attend the Sunday worship services?
  • Are you employed by Brazos Fellowship?*
  • Are you a relative of someone employed by Brazos Fellowship?*

  • PERSONAL BACKGROUND

  • What is the main reason for which you are seeking counseling?*

  • Have you previously received counseling?*
  • Are you currently under the care of a physician or psychiatrist?*
  • Relationship status:
  • Are you a college student?*
  • Do you have any children?*
  • Do the children live in your home?*
  • Have you ever been arrested, charged with, or convicted of a felony?*

  • Expectations:

  • I am interested in a counseling referral for:*
  • What type of counselor do you prefer:*

  • REVIEW & SUBMIT

  • NOTE: Your counseling referral request will not be submitted until you click the "SUBMIT" button. Please review your document and make any necessary changes before submitting.

    If you have any questions or concerns, please feel free to contact us at counseling.referral@brazosfellowship.com

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