Biblical Counseling Request Form

First Name

Last Name

Phone

Texting Okay?

Yes

Age

Marital Status

Single

Married

Divorced

Widowed

If married, how many years?

Spouse's Name

Children's Name and Ages

How long have you attended FCBC?

Are you currently in a Life Group?

Are you presently working with any other counselor, psychiatrist, or medical doctor?

If yes, what reason?

Briefly describe your faith in Jesus:

What are pressing issues or concerns you would like to discuss?

Are you on any medications?

How long have you been on medication?

Are there any issues of addiction, abuse, or suicidal thoughts?

Would you like to meet with a man, woman, or couple?