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Work Entry
Added: 6/30/2025
First Name
First Name is required.
Last Name
Last Name is required.
Street Address
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Email
Email address is not valid
Email is required.
Phone Number
Phone Number is required.
May we text you on this number?
Yes
No
Text Messages is required.
Gender Demographics
Male
Female
Gender Demographics is required.
Age Demographics
Under 18
18-30
31-40
41-50
Over 50
Age Demographics is required.
Military Status
Active Duty or Reserves
Veteran
Military Spouse
None of These
Military Status is required.
Campus
Vacaville Campus
Napa Campus
East Bay Campus
Roseville Campus
Beit Abba
Church Online
Prison Campus
Calgary
Campus is required.
Our goal is to connect you with counseling from one of our local campuses. What campus would you prefer to receiving counseling resources from?
Vacaville
Napa
East Bay
Roseville
No Preference
Our goal is to connect you with counseling from one of our local campuses. What campus would you prefer to receiving counseling resources from? is required.
How many years have you attended TFH?
Number of years at Church? is required.
How many times a month do you attend a weekend service?
Times per month? is required.
Which service do you primarily attend?
8:15am
9am
10am
11am
11:45am
12:30pm
Saturday Slavic Service
Weekday
I Do Not Attend
Which service do you primarily attend? is required.
Please list any TFH Groups you currently attend:
Groups is required.
Small Group Leader(s)
Please list any TFH Ministries you are currently involved with:
List any Ministry Involvment is required.
Are you currently attending or have you attended any of these ministries?
Avenue
Born Identity
Celebrate Recovery
Common Care Counseling
Financeial Peace University
Hope and Recovery for Sexual Abuse
Life Change Event
Live Free healing Ministry
Post Abortion Care
Shelter From The Storm
None of These
Are you now or have you attended any of these ministries? is required.
Are you currently in professional counseling?
Yes
No
Professional Counseling is required.
Please select any of the following areas you struggle with:
Abuse: Physical
Abuse: Sexual
Abuse: Verbal
Abuse: Emotional
Addiction
Anger
Anxiety
Apathy
Authority
Bad Memories
Bitterness
Caring for Parents
Career Planning
Chronic Pain
Codependency
Communication
Resolving Conflict
Compulsions
Depression
Divorce Recovery
Eating Disorder
Education
EmploymentEmpty Nest
Envy
Fear
Greed
Grief
Guilt
Gender Identity
Homosexuality
Humility
Identity
Impatience
Infertility
Insecurity
In-Law Conflict
Jealousy
Judgmental
Leadership
Lifestyle Change
Loneliness
Lying
Manipulation
Marital Intimacy
Moodiness
Panic Attacks
Parenting
Adult Child
Peer Pressure
People Pleasing
Perfectionism
Pornography
Pre-Marital Sex
Pride
Priorities
Procrastination
PTSD
Lack of Purpose
Rebellion
Rejection
Relationships
Respect Spouse
Same Sex Attraction
Self-Control
Self-Injury
Shame
Social Anxiety
Spiritual Growth
Submission
Suicidal Thinking
Time Management
Work Unfulfilling
Other
Struggles is required.
Other, Please Explain:
Why are you seeking Counseling?
Why are you seeking Counseling? is required.
Please give a brief description of the situation & history related to why you're seeking counseling:
History/Current Situation is required.
Please rank your current stress/distress levels (1 = low/no stress; 10 high stress)
Stress/Distress_1-10 is required.
What steps have you taken to date?
What steps have you taken to date? is required.
What do you hope to achieve through counseling?
Goal is required.
Current Living Situation (Please Select All That Apply)
Alone
Parent(s)
Spouse
Children
Boyfriend
Girlfriend
Grandparent
Other
Living Situation is required.
Have you been save and/or baptized? (Please Select All That Apply)
I have received Jesus Christ as my personal savior
I have been baptized
Please give a brief description of your current spiritual life:
If married, what is the name of your spouse?
If married, what is the age of your spouse?
If married, have you and your spouse been separated?
Have you previously been married?
Do you have children? If yes, please list age & gender.
The Father’s House Counseling programs are geared toward short term counseling with long term connections in small groups and/or ministries. Please explain how you heard about the counseling program/how you are connected to The Father’s House:
The Father’s House Counseling programs are geared toward short term counseling with long term connections in small groups and/or ministries. Please explain how you heard about the counseling program/how you are connected to The Father’s House: is required.
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