Counseling Referral Request Entry

Request a Referral to a Local Counselor

Please share your info below and a member of our staff team will reach out with a referral to a local counselor.

First Name

Last Name

Phone

Address

Spouse's First Name (if applicable)

Spouse's Last Name (if applicable)

Guardian's First Name (if under 18 years old)

Guardian's Last Name (if under 18 years old)

How long have you been attending Grace?

How did you learn about this counseling referral offer?

How are you involved at Grace (serving teams, groups, etc.)

Brief summary of issue

If you have insurance that would pay for a counselor, please list provider