Submit A Referral
New Counselee
First Name *
Last Name *
Phone *
May we contact you and leave a message at this number? *
Yes
No
Email Address *
Please note, we will send HCBC related emails to this address.
Gender *
--Select--
Male
Female
Referred to HCBC by (if applicable):
Your First Name
Your Last Name
Your Phone Number
Your Email Address
History
What is the main problem the counselee would like to talk to a Biblical Counselor about? *
Has a Pastor/Elder, or other church leader (e.g. small group leader), been consulted to assist with overseeing those involved and been given the opportunity to shepherd? *
Please feel free to add any other information that may assist HCBC in serving the counselee. *
Type of Counseling *
Check that which applies:
Individual
Marriage
Family
Other
