Youth Counseling Form

We know how hard it can be to ask for help. Completing this form is a HUGE step forward in your journey to experience God’s love and freedom.

Your responses are confidential.

Youth's Information

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Biological Gender

Male

Female

Date of Birth

YYYY

Main Concerns (please be as specific and detailed as you can)

Why are you pursuing counseling? (in your own words)

How would you like your counselor to help you?

Describe your relationship with your father

Describe your relationship with your mother

Describe your relationship with God

Are you open to God's solution?

Parent/Guardian #1 Information

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relation to youth

Main Concerns (from your perspective)

Parent/Guardian #2 Information

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relation to youth

Main Concerns (from your perspective)

How did you hear about us?

Youth Counseling Form

Contact

Business Office Hours

Quick Links

How can we help?