Family Restoration Process(FRP)
Self Referral Form
The Family Restoration Process (FRP) is a space for families to come together, share openly, and begin healing. This is not about judgment or blame, it’s about creating new possibilities and strengthening family connections.Please complete this form so we can better understand who will be participating. All information is private and confidential.
Region/Community the referral is coming from:
Family Information
Family Name:
How many individuals will participate in the process?
Participant 1
Full Name
Age
Participant 2
Full Name
Age
Participant 3
Full Name
Age
Participant 4
Full Name
Age
Participant 5
Full Name
Age
Participant 6
Full Name
Age
Participant 7
Full Name
Age
Participant 8
Full Name
Age
Main Contact Person for the Family:
First Name
Last Name
Relationship within the Family:
Primary Contact E-mail
example@example.com
Primary Phone Number
Format: (000) 000-0000.
How would your family prefer to participate in the Family Restoration Process?
In person
Virtual (online)
A combination of both
Reason for Referral
What brings your family to the Family Restoration Process at this time?
Communication difficulties
Generational trauma
Parenting struggles
Family reunification
Conflict resolution
Other
Please describe the situation in detail
What are you hoping your family will achieve or experience through this process?
Is your family currently connected to any other supports (e.g., community programs, counseling, cultural supports, child & family services, legal supports)?
By submitting this form, you are agreeing to participate in the Family Restoration Process and understand that all information shared will remain private and confidential.
Yes, our family agrees to take part in this process.
No, our family does not agree
Main Contact Person’s Signature:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: