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   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY City State     Postal / Zip Code

Best Contact Phone Number * ( ) - Phone Number

Wife's Date of Birth * 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

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? * Yes No

Do you have any children from a previous marriage or relationship? * Yes No

Do you have any children with your current spouse? * Yes No

Please list ages of children *

Are you a Born-Again Christian? * Yes No

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? * Yes No

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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