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Work Entry
Added: 7/3/2022
First Name
Last Name
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
Phone Number
May we text you on this number?
Yes
No
Gender Demographics
Male
Female
Age Demographics
0-4
5-11
12-17
18-30
31-40
41-50
50-64
65+
Military Status
Active Duty or Reserves
Veteran
Military Spouse
None of These
Do you attend TFH?
No
Yes
What is the name and location of your home church?
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
How many years have you attended TFH?
How many times a month do you attend a weekend service?
Which service do you primarily attend?
Saturday
Sunday - 9AM
Sunday - 11AM
Weekday
Please list any TFH Groups you currently attend:
Small Group Leader(s)
Please list any TFH Ministries you are currently involved with:
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 currently in professional counseling?
Yes
No
Please select any of the following areas you struggle with:
Please select top 3
Abuse: Physical
Abuse: Sexual
Abuse: Verbal
Abuse: Emotional
Addiction
Anger
Anxiety
Apathy
Authority
Bad Memories
Bitterness
Caring for Parents
Career Planing
Chronic Pain
Codependency
Communication
Resolving Conflict
Compulsions
Depression
Divorce Recovery
Eating Disorder
Education
Employment
Empty 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
Other, Please Explain:
Why are you seeking Counseling?
Please give a brief description of the situation & history related to why you're seeking counseling:
What steps have you taken to date?
What do you hope to achieve through counseling?
Current Living Situation (Please Select All That Apply)
Alone
Parent(s)
Spouse
Children
Boyfriend
Girlfriend
Grandparent
Other
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:
What is the name of your spouse?
What is the age of your spouse?
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.:
I agree to continue to attend TFH services & be involved in a TFH Group
I agree to continue to attend TFH services & be involved in a TFH Group
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