Menu
Home
About Us
Our Team
Dr. Zakk Gammon
Kansas Corley
Jeff Harris
Justin Walker
Sheena Barfield
Brittany Evans
Blaire Gammon
Our Story
What Makes us Different
Faith & Ethics
Donate
Christian Counselor Training
Internship Opportunities
Volunteer Opportunities
Employment Opportunities
Services
Adult Counseling
COVID-19 Stress & Isolation
Anxiety
Depression
For Pastors
Alcohol & Drug Addiction
Grief & Loss
From Betrayal to Healing™ – For Wives Only
Porn Addiction
Couples Counseling
Communication
Infidelity & Affairs
Bored Couples
From Betrayal to Healing™ – For Wives Only
Porn Addiction
Couples in Crisis
Drug Addiction Programs
Drug & Alcohol Addiction Counseling
Peer Support & Recovery Coaching
Case Management
Case Management
For Kids
For Teenagers
Rates + Insurance
Appointments
Schedule in Owensboro
Schedule in Hartford
Schedule in Lewisport
Schedule Online Counseling
Blog
Contact + Locations
0
No products in the cart.
Search
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.)