Submit A Referral

Your Information

First Name

Last Name

Home Phone

Mobile Phone

Email

Gender

Age

History

Describe the problem or issue that requires counseling? 

How long has the problem or issue existed?

What's the best way to reach you?

 Marriage counseling is requested

Thank you!

LRBC Biblical Counseling & Care

Thank you for taking the time to complete the biblical counseling referral form. Someone from the team will contact you soon.

Note: Click "Submit" to complete the referral. Once submitted, you will not be able to edit the referral.