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11
Questions
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1
What's your name?
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First Name
Last Name
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2
Are you currently trying to heal and break the cycle of toxic relationships in your life?
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YES
NO
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3
Are you still in the relationship you want to heal from?
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Yes
Yes - but I am SO READY to do the healing work for myself
No
Somewhere in between
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4
Are you in physical danger in the relationship?
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YES
NO
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5
Why are you interested in applying for Heal, Rise, Thrive at this time?
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6
What have you done or are you currently doing to support your healing?
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Therapy or Counseling
Coaching
Energy Healing
I was getting support but can no longer afford it
Nothing - But I am SO ready for support
Nothing - I can not afford it
Other
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7
Heal, Rise, Thrive is a significant financial investment. Are you prepared to invest in yourself and your healing NOW?
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YES
NO
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8
When you imagine yourself 6 months from now, what would you ideally like your life and relationships to be like? What is your vision for yourself when it comes to healing?
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9
After we review your application, What is the best email to reach you?
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example@example.com
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10
At this time it does not seem that you will be a good fit for the Heal, Rise, Thrive program. Would you like us to send you other options that do not require a large financial investment? If yes, please put your best EMAIL below.
example@example.com
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11
At this time, Heal, Rise, Thrive will not be the best place for you. We suggest reaching out to https://www.thehotline.org for resources to get help.
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