Leaping Forward

RCCG EMR 1 & 6 YAYA

Counselling Signup

YAYA Summer Camp 2026 | 24–26 July 2026 | The Netherlands

Full Name

Age

Gender

Male

Female

Phone number*

Email address

Other counselling areas not listed above

Briefly describe what you would like support with

Have you sought any support for this before?

No, this is my first time

Yes, with a counsellor or therapist

Yes, with a pastor or church leader

Yes, informally with a friend or family member

Session Preferences

1:1 with a counsellor

Prayer session only

Group session / breakout group

No preference

Do you have any preference for the gender of your counsellor?

Male counsellor

Female counsellor

No preference

Preferred time slot (subject to availability)

Morning (before 12pm)

Evening (after 4pm)

Afternoon (12pm–4pm)

No preference

Which camp day(s) are you available?

Friday 24 July — Leaping Forward

Saturday 25 July — Leaping Forward

Sunday 26 July — Leaping Forward

Any day

Consent & Agreement (Please read and tick each statement to confirm your agreement)*

understand that this session is confidential and my information will not be shared without my consent, except where required for safeguarding..

I understand that counsellors are trained volunteers from RCCG EMR 1 & 6 YAYA providing biblically-based guidance, and are not professional therapists or licensed mental health practitioners.

I consent to session notes being taken by the counsellor for the purpose of this session only.

I am willing to be referred to pastoral leadership or an external professional if the counsellor deems it appropriate.

CONFIDENTIALITY NOTICE

All information provided on this form is strictly confidential and will only be used to assign you to an appropriate counsellor. Your details will not be shared with anyone outside the counselling team without your consent, except where there is a risk of harm to yourself or others.