Biblical Counseling Intake Form Please fill out all sections of the form. If you do not have time, there is a ‘save & continue later’ link in each section so that you can come back and finish later. 1 Personal Information2 Demographic Info3 Household Info4 Addiction Info5 Lodging & Payment Program Date Requested* Select the program start date.Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last 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 What County do you live in ?*Best Phone #*Best Email Address Emergency Contact InformationName of Emergency ContactRelationship to ContactBest Phone # for Contact Save and Continue Later What is Your Birthdate ?* MM DD YYYY GenderMaleFemalePrefer not to answerMarital StatusSingleMarriedDivorcedSeparatedWidow/WidowerRace White Black/African American American Indian/Alaska Native Asian/Pacific Islander Other Education Some High School High School Graduate GED Vocational/Technical School 2YR Degree 4YR Degree Graduate Degree Doctorate Degree Please select all that apply.Employment StatusFull-timePart-timeHomemakerStudentUnemployed-Temporary/SeasonalUnemployed-Long TermEmployer (if applicable)Are you a veteran ?YesNoDates of Service Save and Continue Later HousingOwnRent/LeaseGroup QuarterHomelessOtherHousehold Size123456 or moreHousehold Annual Income - All SourcesLee that $10,000$10,000 - $14,000$15,000 - $24,999$25,000 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 - $99,000$100K - $149K$150K - $199K$200K + Save and Continue Later Addiction Problems to AddressHow did you hear about Addicts Victorious ?Home Church Save and Continue Later Do you need a Hotel room ?YesNoSmoking/non-smoking room ?SmokingNon-smokingWhen do you need to check in ?Sunday NightMonday MorningPayment/Financial InformationNo payment is required at this time. We will contact you with payment details after filling out the information below.How do you intend to pay for the program ?Credit/Debit CardCheckI am requesting financial assistanceIf you require financial assistance, please select that option and we will contact you to work out the details.Amount you could payPhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.