Biblical Counseling Request

Name*

First Name

Last Name

Email*

Date of Birth*

Gender*

Male Female

Phone*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Do you attend The Village Church?*

Yes No

Which campus do you attend?

Flower Mound Fort Worth Southlake

Since you do not attend The Village, please select the campus closest to you.

Are you a Covenant Member?

Yes No

Are you in a Home Group?

Yes No

Who is your Home Group leader?

Are you in a Recovery Group?

Yes No

Who is your Recovery Group leader?

Are your current circumstances in any way physically, emotionally or spiritually unsafe?*

Yes No

Please explain:

What type of counseling are you seeking?*

Individual Couples Family

Do you have a preference of gender for a counselor?*

Male Female No preference

If you are willing, will you share some of why you'd like to be referred to a counselor? This helps us get you to specialized care, if needed.

Have you talked to a pastor or staff member about why you'd like to see a counselor?*

Yes No

Whom?

Would you be open to meeting with a man or woman on staff at The Village to talk about what is going on?*

Yes No