Counseling Request Form

Made Alive Conference! Here is an opportunity to dig deeper into these tunnels, seasons, and struggles of life.

If you are interested in Christian counseling, sign up here.

Your name *

Email address *

Phone number *

Birthdate

Grade

Best Days and Times to Reach You

Primary Goals for Seeking Counseling (Check all that apply): *

Manage struggles with anxiety, depression, or stress from a Christian perspective

Receive support for romantic relationship or family challenges grounded in Christian values

Receive guidance through grief, loss, or life transitions with spiritual encouragement

Overcome guilt, shame, or forgiveness struggles with biblical counsel

Strengthen personal faith and relationship with God during difficult times

Address trauma or past experiences through a faith-informed lens

Receive support with decision-making, purpose, and life direction aligned with Christian beliefs

Obtain accountability and encouragement in living out biblical values

Share some of the main challenges that you would like to address:

Sessions will be Approximately 45mins, lasting until Spring 2026 The goal is that they would be consistent (weekly or twice a month)

Best Times for Counseling (check all time frames that apply): *

Late Morning / Early Afternoon (11-2pm)

Late afternoon (2-5pm)

Early Evening (5-7pm)

Late Evening (7-8pm)

Please note any other specific times that will work best for you (We cannot make any guarantees, but will make every effort to accommodate)

Please Note:

Please note that if you are under the age of 18, we would like to obtain consent from your parent or guardian. Information will not be shared with parents or guardians outside of concern of harm to yourself or others. Your parent and guardian will not be informed of the details of information held in counseling

Primary Parent/Guardian Name

Primary Parent/Guardian Phone Number