ReStory® IntensivesIndividual and Marriage Intensive Application Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Line Is this for an individual or marriage intensive? If this is for a marriage, both spouses must complete the application. * Please tell us about your interest in an Intensive. What about it interests you? * * Tell us what areas of your life and story 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. * Which therapist do you prefer? * Chris Bruno Tracy Johnson Lindy Pearson CJ Rithner Of the available dates of this therapist, which one are you requesting? * The 2024 cost of ReStory® Intensives is $3,750 (including deposit) for individuals and $4750 for couples. Do you acknowledge the cost? * * Intensives include 15 hours of storywork counseling with ReStory Experts, pre-work and engagement, and 2 post-intensive sessions for re-entry. Yes I'll need a payment plan I am interested in setting up a 3 or 6 moth pre-payment plan. Please let me know more information on this? * 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.
