Client Application
Salutation
Please select...
Dr.
Mr.
Mrs.
Ms.
Filler
First Name
Last Name
Cell Phone
Home Phone
Permission to leave Confidential voicemail
Yes
No
Email
Is this application on behalf of a Child
Yes
No
Child's First Name
Child's Last Name
Child's Birthday
Gender
Please select...
Male
Female
Are you the legal Guardian
Yes
No
Do you authorize us to refer your child to an authorized counselor?
Yes
No
Who is the legal guardian and what is their contact Info?
Home Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
Ministry / Institution
To help narrow the search for your church, please select the church's physical city first.
City Name
Church Name
Church Address
City ID
Church ID
Church Not Found
Please Contact Texas Baptists Counseling Services to proceed with this applications. You may contact them at
counselingservices@texasbaptists.org
or by phone at (214) 828-5188
Ministry Role / Position at Church
Insurance
Do you have insurance?
Yes
No
Provider
Do you have a copay?
Yes
No
Copay
$
Counseling Information
Do you have a counselor in mind?
Yes
No
TXB Counselor
Please first search for the email of your prefered counselor in the email field. Select the correct email. Check that the Name and Phone Number fields are correct.
Email of Counselor
Name of Counselor
Phone Number of Counselor
Counselor ID
Please answer the rest of the questions in case your prefered counselor is not available.
Preferred Counselor Not Found
Prefered Counselor Not Found
Name of Counselor
Phone/Email
Email of Counselor
Phone Number of Counselor
Address of Counselor
Please answer the rest of the questions in case we do not work with your prefered counselor.
Do you have a preference on the gender of the Counselor?
Male
Female
No Preference
Do you have a c
ounseling preference
Online
In Person
No Preference
What is the Nature of your Request for Counseling?
Referred by
BSM
CPlanter
Other
How did you hear about us?