LIBERTY INSTITUTE OF FAITH-BASED COUNSELING
Enrollment Application
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Name ___________________________________________
Date of Birth ___________________
US Mail Address __________________________
City _____________ State ___ Zip _________
Email Address ____________________________________
Cell ________________________
Last Formal School Grade Completed ______ Major ________________
Church or Sponsor __________________________________
Pastor or Sponsor ___________________________________
Church / Sponsor Address _____________________________
City ________________ Zip _________
Will you be counseling with this church or Treatment Center _______
Phone _______________
Professional Licenses or Vocational School Training
___________________________________________________________
Please tell us of any counseling experience you already have
___________________________________________________________
In consideration of Liberty Institute of Faith-Based Counselors accepting the undersigned as a student of its
Faith-Based Counseling Certification Program, the undersigned agrees to pay appropriate scheduled fees and
acknowledges that no refund will be made for any reason.
Student understands and agrees to hold harmless and without liability in any form; Liberty Institute, it’s staff,
facility or representatives, for the use of, or understanding of materials taught, or any action taken on the part
of the student.
To maintain Certification Liberty Institute requires all Counselors to complete 3 hours annually of Continued
Education and pay a renewal fee of $25. (Notice will be mailed to address of record.)
In acceptance of this student’s application and registration, Liberty Institute of Faith-Based Counseling agrees
to provide to the undersigned a complete course in Christian Counseling Education instruction in accordance
with its regularly developed or special curriculum.
I am applying as a student for the following course(s)*
___ Certified Faith-Based Counselor (Three study courses - $450)*
___ Course One - Counseling Basics, Legalities, Ethics, Treatment Center Operation. $150
___ Course Two - Clinical, Pastoral Counseling. Marriage, Family & Mental Health. $150
___ Course Three - Chemical Dependence, Domestic Violence, Suicide, Smoking. $150
This the _______ day of ________ , 2__________
________________________________________
Signature
Make checks payable to:
LIBERTY INSTITUTE OF FAITH-BASED COUNSELING
PAYMENT ENCLOSED $ ____________ Check # ______________
*If you pay tuition with a credit card, please pay complete tuition with registration. Contact us for
credit card instructions.
*If you choose to study one course, you will have 30 days to complete and order your next course.
You will test at the end of Course Three. Materials may change without notice.
* If you have a problem adding your information to this page, you may copy and paste into MSWord.
Complete the enrollment page and mail with your tuition payment to:
Liberty Institute of Faith Based Counseling
108 Royal Ln.
Commerce, TX 75428
