Unwanted Sexual Behavior Counseling IntensivesIndividual Intensive Application Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Line Please tell us about your interest in an Intensive. What about it interests you? * * Tell us more about what's going on in your life and story that you want to address? * Are you currently in counseling? * Yes No No, but I used to No, but I want to If so, with whom, when, and for what duration. Tell us about what you've been working on together. * How dire are your current circumstances? * I am okay right now, but would like to address this ASAP. Strongly Disagree Disagree Neutral Agree Strongly Agree I would like to address this in the next 12 months. Strongly Disagree Disagree Neutral Agree Strongly Agree Have you ever had any official diagnoses for mental/emotional health related concerns? If so, tell us a bit about that. * * Have either of you ever struggled with self-harm or suicidal thoughts? If so, please describe. * Many of our clients participate in a faith community. Tell us a bit about your faith journey. * Of the available dates of this therapist, which one are you requesting? * The 2025 cost of these Intensives is $2,750 (including deposit) for individuals. Do you acknowledge the cost? * * Intensives include 15 hours of storywork counseling, pre-work and engagement, and 1 post-intensive session. Yes I'll need a payment plan I am interested in setting up a 3 or 6 moth pre-payment plan. * Yes No If your application is approved, we will collect a non-refundable $500 deposit to secure your spot. Payment is due in full by two weeks before the start date. Do you accept this policy? * Yes I need to talk with you How did you hear about us and the ReStory Intensives? Please be as specific as possible. * Is there anything else we should know? * Thank you so much! We will get back to you within 24 hours about next steps! Thank you! Our ReStory Experience Coordinator will be in touch shortly.
