Name*

Phone*

Street Address*

City*

State*

Zip*

Terms:
This Counseling Program is Bible-based and is administered to those who ascribe to the teaching of the Word of God. This program is NOT meant to replace any medical or professional input. By choosing this program, you waive all your rights to sue or expose the staff or ministry of the International Outreach Center to any lawsuits under any circumstances whatsoever. All information given is volunteered for the purpose of this counseling. The International Outreach Center, it’s staff and members will not be liable for any bad decisions made because of the choices you make for your life. By choosing this program, you consent to the terms stated above.

Note: All Fields are Required. You must agree our terms statement to receive counseling.
Click "Agree and Continue to go to our Marital Counseling Application

Give a mission statement for your marriage.

Name of your fiance

Are there children involved?

Past Relationships:
Is this your first Marriage?

If not your first Marriage, explain

Is the past marriage dissolved?

If Yes,when?

Do you live together?

Areas of Counseling - Check all that apply

Enter Security Code