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

Wife's Name *  
First Name Last Name
Husband'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
Wife's Date of Birth *
Email *
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? *
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