Apply for Assistance

Please complete the application below.

Assistance Application

Our partnership with community organizations and members and their generosity, make it possible for individuals, couples, and families to access quality, faith-based counseling when they may otherwise be unable to afford such services.

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
Personal Information
Please answer the following questions as completely and accurately as possible. Some of them may feel uncomfortable, but we want to understand your situation as best as possible, so we can pull together the resources you need.
Why are you seeking Christian Counseling services? What do you hope to achieve through your time at Revive?*
Are you currently employed?*
- Yes
- No
Are you currently looking for work?*
- Yes
- No
How do you currently make ends meet?*
What is keeping you from being able to look for work? Is this a resource we can help with as well?*
What's your current salary?*
(Examples: $7.50 per hour or $17,000 per year)
Please upload your last two pay stubs from work. Images or PDF copies are acceptable.*
If you don't have access to your paystubs right now, you can click "Save and continue later" at the bottom of this application. You can come back and complete the application after you've located those pay stubs.
Drop files here or
What do you think you can *reasonably* pay for counseling services per session?*
As funds are limited, we want to ensure as many people as possible have access to care. As such, we ask you to prayerfully consider what amount, if any, you can contribute to your counseling sessions.
- $0 - Any payment amount would be too much to make ends meet.
- $5-$10 per session
- $10-$15 per session
- $15-$20 per session
- $20-$25 per session
What else would you like for us to know as we consider your application?
(Examples: a major car repair, a major life change, unexpected medical bills, etc., and other life situations that are affecting your finances.)

Save and Continue Later

Assistance Application

Personal Information