Marriage Counseling Request Form (Husband)
*All information submitted will remain confidential.

Husband's Name *  
First Name Last Name
 
Wife's Name *  
First Name Last Name
   
Current Mailing Address *
Street Address
 
Street Address Line 2
 
City State
 
 
Postal / Zip Code  
 
Best Contact Phone Number *
( ) -
Phone Number
 
Husband's Date of Birth *
 
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
   
 
How many years have you been married? *
 
Have you been married previously? *
 
Do you have any children from a previous marriage or relationship? *
 
Do you have any children with your current spouse? *
 
Please list ages of children *
 
Are you a Born-Again Christian? *
 
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 to anyone at Grace Church, or to anyone else? *
 
Are you currently seeing, or have you seen, a counselor about this? *
 
If you have seen a counselor, but not for the same reason, then why?
 
What results are you expecting from counseling? *
 
 
 
©2021 Daphne Software, Inc.