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*

MonthDayYear
Date
First Name*
(Primary)
Middle Initial*
(Primary)
Last Name*
(Primary)
Care ID #
(Primary)
Gender*

MaleFemale
Age*
(Primary)
Phone Number*

Area Codexxxxxxx
Email*
example@example.com
Address*

Street Address

Apt.

CityState

Zip Code
SECONDARY INFORMATION

Child or Dependent
First Name
(Secondary)
Middle Initial
(Secondary)
Last Name
(Secondary)
Care ID #
(Secondary)
Gender

MaleFemale
Birthday (Secondary)

MonthDayYear
Date
Phone Number

Area Codexxxxxxx
Email
example@example.com
Church Engagement
Indicate your level of engagement at Brazos Fellowship:

New GuestAttendeeMinistry VolunteerMinistry LeaderSmall Group MemberClass ParticipantYouth MinistryCollege MinistryOther
If you attend our church, how often each month do you attend the Sunday worship services?

1 time2 times3 times4+ times
If you're a member of a Small Group, what is your leader's name?*
n/a if none
In which ministry are you currently volunteering?*
n/a if none
Are you employed by Brazos Fellowship?*

YesNo
Are you a relative of someone employed by Brazos Fellowship?*

YesNo
PERSONAL BACKGROUND
What is the main reason for which you are seeking counseling?*

AdoptionAddictionAlcoholismAnger ManagementAnxietyCareerChild AbuseChildrenCodependencyCommunicationDepressionDisabilitiesDivorce/SeparationEating DisordersFamily DynamicsFamily StressorsFinancesGrief and LossHealth and WellnessHolistic HealingHomosexual IssuesInfertilityLife TransitionsMaritalMental IllnessMid-Life CrisisMissionary Re-entryParentingPhobiasPhysical AbusePost Abortion CounselingPost Traumatic StressPre-MaritalRape RecoveryRelationshipsSelf EsteemSelf HarmSexual AddictionSexual Assault / AbuseSexual HealthSexual IdentitySpiritual IssuesSubstance AbuseSuicideTerminal IllnessTraumaOther
Please share details about why you are seeking help:*
When did you first notice this concern?*
Have you previously received counseling?*

YesNo
If so, when and what was the name of your counselor(s)?
What were the results of your counseling?
Are you currently under the care of a physician or psychiatrist?*

YesNo
Please list any additional information about medical or psychological concerns that would be important for us to know:*
Relationship status:

DivorcedEngagedSingleLiving TogetherMarriedSeparatedWidowed
Are you a college student?*

YesNo
If so, which school do you attend?
College / University
Do you have any children?*

YesNo
Do the children live in your home?*

YesNo
Ages(s) of children?
Name(s) of children?
Have you ever been arrested, charged with, or convicted of a felony?*

YesNo
Please explain:
Expectations:
I am interested in a counseling referral for:*

Individual CounselingCouples CounselingFamily CounselingGroup Counseling
What type of counselor do you prefer:*

MaleFemaleEither
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
Type a question
Should be Empty:

Counseling Referral Request

Directions:

PRIMARY INFORMATION

SECONDARY INFORMATION

Church Engagement

PERSONAL BACKGROUND

Expectations:

REVIEW & SUBMIT