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
Postal / Zip Code  
Best Contact Phone Number *
( ) -
Phone Number
Date of Birth *
Email *
Education (Level, School, Major)
What is your personal status? *
Single Married
Engaged Separated
Divorced Widowed
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
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 check the appropriate boxes for the type of counseling needed
  Anger Issues Spiritual
Financial Grief
Depression Marriage/Family
Divorce Recovery Sexual Addiction
Pornography Chemical Dependency
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
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.
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