SUPPORT SERVICES APPLICATION

Restoration Care

Counseling, care, and support offered by licensed and trained professionals who understand trauma and addiction as well as restoration and recovery. By completing the form on this page, you are able to apply and request support and counseling services.

SUPPORT SERVICES APPLICATION

(please complete this form and click the submit button to apply)

Name

First Name

Last Name

Email

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Are you an overcomer of any form of commercial sexual exploitation (stripping, escorting, sex trafficking, pornography . . . )? *

Yes

No

When was the last time/day you used substances (including alcohol)? *

Please be honest with yourself and us. We simply want to understand how we can best serve you.

Message *

Is there anything you'd like for us to know?

What Service are You Interested In? *

In Person, Out-Patient Support + Counseling Services

Online,Out-Patient Support + Counseling Services