General InformationType of Counseling RequestedType of Counseling*Choose OneMaritalPremaritalWoman to WomanMan to ManMarital, Emergency?*Select OneYesNoPlease give a brief description as to why this is an emergency.*Premarital, Wedding Date Today's Date* Name* First Last Email* Fiancé / Spouse's Name* First Last Fiancé / Spouse's Email Phone*Applicant Age:*Age of Fiancé / Spouse:Number of Children:*Ages of Children:Is this a blended family?* Yes No Years Attending The House?*If not, where do you go to church?*Classes / ServicesHave you completed Growth Track classes at The House?*YesNoIf so, when?*Do you regularly pay tithes (10% of income) to The House?*YesNoOfferings?*YesNoAre you and your fiancé / spouse willing to come in together?*YesNoIf so, when?*How many years have you been together?*How many years have you been married?*First marriage for applicant?* Yes No First marriage for Fiancé / Spouse?* Yes No Reason for services?*Are you involved with any ministries at The House?* Yes No If yes, which ministry are you a leader in?*Check any of the following classes that you are or have been involved with:* Prayer / Altar Team Beautiful Warrior's Curriculum Counseling Center The House Men Curriculum Women of Influence Beauty for Ashes / LACE Successful Relationships Class/Family Strong King's University / SEU CROSS Recovery Growth Track Grief Share I am not involved in any classes at The House Other If "Other", what classes were / are you involved in?*Are you a leader/mentor in any ministry?*YesNoIf so, which ministry?*Have you received mentoring from anyone at The House before?*YesNoIf so, what are their names?*May we call them about your situation?*YesNoIf so, what is their contact information?*Are any of the following conditions involved?* Suicidal Tendencies Physical Abuse Depression Health Problems Sexual Abuse Pornography Violent Behavior Occult Activity Substance Abuse Sexual Addiction Financial Hardship Mental Disorders Eating Disorders Criminal Activity Separation / Divorce Adultery/Affair Other If "Other", describe*By submitting your application, you are agreeing to pay a $35 fee, for an additional online assessment prior to the scheduling of a counseling session.Once we receive your application, one of our counselors will be in contact with you to give you further information.