Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Age Marital Status * Have you had professional counseling before? If you have, please describe Have you received Jesus Christ as your Savior? Do you attend church? If so, where? Why are you seeking Biblical Counseling? What is the extent of your need? Severe Moderate Please describe your main problems, areas of concern or needs Please describe any life-altering events you've experienced within the last two years How did you hear about Restoration Biblical Counseling? Emergency Contact Name, number, and relationship to you Would you like your appointments to be online or in person? Online In Person Thank you!