Counseling Request

If filling out form as a couple, and answers vary, please answer for both by initialing the separate answers.

Today's Date *

Full Name *

First Name Last Name

Phone Number *

- Area Code Phone Number

Spouse (if applicable)

First Name Last Name

Phone Number

- Area Code Phone Number

Physical Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *

Your E-mail Address

Marital status? *

If married, is this your first marriage? *

Yes No

What best describes your relation to Fondren Church? *

Active Member (I have joined Fondren Church and attend regularly) Inactive Member (I have joined Fondren Church, but seldom attend) Regular Attender (I call this my church home, but have not become a member)) I am not a member and seldom, if ever, attend Fondren Church

Are you connected with a Pastor at Fondren Church?

Yes No

If yes, which pastor are you connected with?

Are you part of a Small Group at Fondren Church? *

Yes No

If yes, what small group are you a part of?

Are you a member of another church, and if so, how often do you attend?

Briefly describe your job including total family income and medical insurance coverage (if filling this out as a married couple, please describe both): *

Have you had previous experience with counseling? *

Yes No

If yes, what type of Counseling

Marital Family Individual

Number of Sessions

1-5 6-10 11-20 21 or more

Agency or Counselor

If previous counseling experience, how would you describe your reaction to counseling?

Not satisfied Somewhat satisfied Satisfied

If you had several counseling experiences and your reactions varied, please explain:

How did you hear about Fondren Church's Counseling Ministry?

Friend Minister Physician Fondren Member Website Other

Please describe how you hope we can help you:

How would you rate the intensity of your need?

Mild Moderate Severe

"In-house" counseling provided by Fondren Church is short-term and is designed to assist you in finding help that is appropriate for your situation. If ongoing support will be needed, which of the following would you be interested in?

Groups: Ongoing and short-term small groups provide a safe atmosphere for you to connect with others. Your group leader will help guide the discussion/study and insure that everyone is engaged in the group process. Speak with your intake counselor about group options at Fondren. Local Professional Christian Counseling: Fondren Church utilizes local Christian counselors who are licensed and trained to provide you with the expertise you need, but will also approach your situation from a biblical point of view. Discipleship Mentor: This ministry is designed to help you grow in your walk with Christ by partnering you with a discipleship mentor. The two of you will meet once a week to pray, study God's Word and connect relationally. Your mentor may give you assignments that are geared to help you grow spiritually. Marriage Mentoring: Using a marital assessment tool called Prepare, your mentor couple will walk with you through areas of your marriage that are strained and/or will help you to make a good marriage even better. Usually involves 4-6 meetings with mentor couple.

How would you describe your relationship with Jesus Christ? *

I have accepted Jesus as my Lord and Savior, and have a growing relationship with Him. I have accepted Jesus as my Lord and Savior, but am at a standstill in my relationship with Him. I accepted Jesus as my Lord and Savior, but have drifted away from Him over time. I have never accepted Jesus as my Lord and Savior. I am unsure about my relationship with Jesus.

Counseling Request

Contact Information

Previous Counseling Experience