Personal Data Form

Counseling Request

To allow us to be efficient at helping, we kindly ask you to fill out this important document that will provide us with some important information needed in order to set up your initial appointment. As soon as possible after receipt we will contact you to set up an appointment.

Personal Data Inventory (PDI) Form
* Name:
* Address:
  Address:
* City:
* State:
* Zip:
* Birth Date:   (mm/dd/yyyy)
* Daytime Phone:
  Evening Phone:
  Cell Phone:
  E-Mail:
  Referred By:
* Do we have permission to contact you regarding counseling?
* Preferred Contact Method:
     
  SECTION I -- MARITAL STATUS
* Current Status:
  Spouse's Name: (if applicable)
  Spouse's Age:
  Years married:
  Number of Children:                   1 2 3 4 5
  Rate your marriage (1 as terrible, 5 as excellent) 1 2 3 4 5
  SECTION II -- OCCUPATIONAL STATUS
* Employed:    If No How long?
  Current Occupation:
  Gross Household Income $:
  SECTION III -- Religious Status
* Do you currently attend church?    Where?


  Why do you want to receive Pastoral/Biblical Counseling and how can we help?
 
     

 
* Verification Check:

Type the characters that you see in this picture.


Characters are not case-sensitive.

When finished please click the Submit button.

 

903-894-8131 | [email protected] | Galatians 6:2 Counseling Ministry | 19545 Norfolk Drive  | Flint TX 75762
"Providing ministry to Tyler, Bullard, Flint and East Texas"

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