COUNSELING FORMSMission Hills Church Teen Counseling Request Form (ages 13 and up)Requestor InformationAre you a parent completing this form on behalf of your teen?*YesNoName of Parent* First Last Parent Phone*Parent Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Teen InformationName of Teen* First Last Age*Gender*FemaleMaleSchool*Grade*Has your teen had any professional counseling before?*YesNoIssue seeking counseling for:*Extent of NeedExtent of Need*Life ThreateningSevereMild** If you are in a life threatening situation, please dial 911 or contact your local authorities. **What have you previously attempted or done to resolve this problem?*Please describe if there are any people, situations, or activities that seem to trigger this problem or make it worse:*Personal HistoryHave any life altering changes occurred within the past 2 years?*YesNoIf yes, please describe.Spiritual InformationWhere is your church home?*Mission Hills ChurchWe don't have oneOtherIf other, where?Do you believe your teen has accepted Jesus Christ as their Savior?*YesNoIs your teen active in church?*YesNoIf yes, please describe.Health InformationPlease rate your teen's health:*Very GoodGoodAveragePoorPlease list any significant illnesses, injuries, or other health concerns.*Please list any medications they are currently taking.*Has your teen ever experimented with or is taking illegal drugs?*YesNoI don't knowIf yes, please describe.EmailThis field is for validation purposes and should be left unchanged.