COUNSELING APPLICATION Counseling Application Name * Mailing Address * Mailing Address * Mailing Address * Mailing Address * City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone Cell Phone * Email * Confirm Email * Confirm email address Birthday * Gender * Male Female Marital Status * Single Married Separated Divorced Widowed Are you currently employed? * Yes No Occupation * Place of Employment * Work Address * Work Phone * Is Times Square Church your home church? * Yes No how long have you been attending * Less than a year 1 - 5 years Over 5 years Which services do you attend regularly? * Sunday 10AM Sunday 1PM Sunday 3PM Sunday 6PM Tuesday 7PM Which church do you attend? * Have you received previous counseling at Times Square Church or elsewhere? * Yes No With whom? * For how long? * What type of counseling are you seeking? * Pre-marital (couples must apply separately) Marital Family Life Issues Is your spouse willing to come in? * Yes No Full Name of your spouse * Full Name of your fiance * Describe the reason you are seeking counseling (please be specific) * List the goals you hope to achieve through counseling * PLEASE BE ADVISED: As church counselors we are not professionals, licensed psychologists or psychiatrists. We simply offer Christian counseling based on the Word of God and an opportunity for prayer led by the Holy Spirit. Please be prompt for your appointments and make arrangements for childcare during your sessions as childcare is not provided. I agree PLEASE NOTE: We will attempt to get in touch with you three times. If after the third attempt we fail to get in touch with you, you must submit a new application for counseling. I agree
