Counseling Assistance Form – First Alliance Church

Internal Benevolence Request for Counseling Expenses

Please complete this form entirely and allow 5-7 business days for a reply.

"*" indicates required fields

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Number of children and ages

Name of spouse

Current employment status*

After praying, I believe I am supposed to contribute the following amount toward my counseling expenses for myself or my family member.*

What circumstances have led to your need for financial assistance?*

How frequently do you attend FAC?*

Please provide any other details that may be helpful in processing your request.*

Name

This field is for validation purposes and should be left unchanged.