Counseling Referral Request

Counseling Referral Request

BF Care Network
Directions:

"Primary" indicates the person requesting a counseling referral. "Secondary" indicates Spouse/Significant Other/Child/Family Member also included in counseling referral request.
PRIMARY INFORMATION
Today's Date *

Month Day Year
Date Date Picker Icon
First Name *
(Primary)
Middle Initial *
(Primary)
Last Name *
(Primary)
Care ID #
(Primary)
Gender *

Male Female
Age *
(Primary)
Phone Number *

Area Code xxx xxxx
Email *
example@example.com

Address *

Street Address
Apt.
City	State
Zip Code	Country

SECONDARY INFORMATION

Child or Dependent
First Name
(Secondary)
Middle Initial
(Secondary)
Last Name
(Secondary)
Care ID #
(Secondary)
Gender

Male Female
Birthday (Secondary)

Month Day Year
Date Date Picker Icon
Phone Number

Area Code xxx xxxx
Email
example@example.com
Church Engagement
Indicate your level of engagement at Brazos Fellowship:

New Guest Attendee Ministry Volunteer Ministry Leader Small Group Member Class Participant Youth Ministry College Ministry
If you attend our church, how often each month do you attend the Sunday worship services?

1 time 2 times 3 times 4+ times
If you're a member of a Small Group, what is your leader's name? *
n/a if none
In which ministry are you currently volunteering? *
n/a if none
Are you employed by Brazos Fellowship? *

Yes No
Are you a relative of someone employed by Brazos Fellowship? *

Yes No
PERSONAL BACKGROUND
What is the main reason for which you are seeking counseling? *

Adoption Addiction Alcoholism Anger Management Anxiety Career Child Abuse Children Codependency Communiation Depression Disabilities Divorce/Separation Eating Disorders Family Dynamics Family Stressors Finances Grief and Loss Health and Wellness Holistic Healing Homosexual Issues Infertility Life Transitions Marital Mental Illness Mid-Life Crisis Missionary Re-entry Parenting Phobias Physical Abuse Post Abortion Counseling Post Traumatic Stress Pre-Marital Rape Recovery Relationships Self Esteem Self Harm Sexual Addiction Sexual Assault / Abuse Sexual Health Sexual Identity Spiritual Issues Substance Abuse Suicide Terminal Illness Trauma
Please share details about why you are seeking help: *
When did you first notice this concern? *
Have you previously received counseling? *

Yes No
If so, when and what was the name of your counselor(s)?
What were the results of your counseling?
Are you currently under the care of a physician or psychiatrist? *

Yes No
Please list any additional information about medical or psychological concerns that would be important for us to know: *
Relationship status:

Divorced Engaged Single Living Together Married Separated Widowed
Are you a college student? *

Yes No
If so, which school do you attend?
College / University
Do you have any children? *

Yes No
Do the children live in your home? *

Yes No
Ages(s) of children?
Name(s) of children?
Have you ever been arrested, charged with, or convicted of a felony? *

Yes No
Please explain:
Expectations:
I am interested in a counseling referral for: *

Individual Counseling Couples Counseling Family Counseling Group Counseling
What type of counselor do you prefer: *

Male Female Either
REVIEW & SUBMIT
NOTE: Your counseling referral request will not be submitted until you click the "SUBMIT" button. Please review your document and make any necessary changes before submitting.

If you have any questions or concerns, please feel free to contact us at counseling.referral@brazosfellowship.com
Type a question
Should be Empty:

Counseling Referral Request

Directions:

PRIMARY INFORMATION

SECONDARY INFORMATION

Church Engagement

PERSONAL BACKGROUND

Expectations:

REVIEW & SUBMIT