Free Marriage and family Counseling Evaluation


We are happy to be able to provide a Free Marriage and Family Counseling Evaluation.

Complete Your Confidential Marriage and Family Counseling Evaluation Form
We will receive this form and then we will be able to provide you with a free telephone Marriage and Family Counseling Evaluation session.

Make sure that you take your time filling out the form and make sure that all the information is accurate. The more information you give us the better we will be able to help you.
If you are a pastor of someone else trying to contact us with a simple question or comment please feel free to click here and contact us using our short form.

Fill Out Form Below For Free Marriage or Family Counseling

Fields with a * are required:

*Full Name:
*E-mail Address:
Street Address:
*Zip Code:
Date of Birth:
*Gender: Male Female
*Relationship Status:
Time Lived at Current Residence:

*If you have ever received counseling/psychiatric services, please describe:

Level of completed education:


*If you are taking any medications, please list name and dosage:

*Describe the problem below, providing as much information as possible:

Terms of Use Agreement

Please read the following, then click on "Submit" to send your information. By clicking Submit you are agreeing to the "Terms of Use Agreement."

  • You must be over 18.
  • People experiencing suicidal feelings, crisis situations, alcoholism, drug abuse, various types of abuse, violent relationships, eating disorders, and severe mental illnesses should work with a face to face therapist. For emergency help call 911, or go to your nearest hospital emergency room, or call the national Suicide Hotline at 1-800-SUICIDE.
  • By using these services you acknowledge the limitations inherent in ensuring client confidentiality of information transmitted through the Internet and by telephone.
  • By using these services you agree to Pastoral Biblical Counseling.
  • I will keep our correspondence secure on my own personal computer. All information is kept confidential with the exception of legal requirements to report child abuse, danger to others or danger to self.
  • If your problem is beyond my scope of expertise, I will immediately inform you of such.


Crisis Family Care will NEVER abuse your trust
by sharing your e-mail address or any other personal information
without your explicit consent.