Restoration in Motion Application
Thank you for your interest in Restoration in Motion Mentorship. This application is designed to help me learn more about you, where you are in your journey, and whether this support may be a good fit. After reviewing your application, I may reach out to schedule a brief phone conversation.
Please note: Restoration in Motion Mentorship is not therapy, counseling, medical care, or crisis support. It is a mentorship-based service designed to support personal growth, restoration, and next-step living for people in recovery.
Basic Information
Full name
*
First Name
Last Name
Email address
*
example@example.com
City and state
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to contact you
*
Phone
Text
Email
Best time to contact you
*
Morning
Afternoon
Evening
How did you hear about Restoration Mentorship?
*
Your Current Season
Which best describes where you are in your recovery journey right now?
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Newly in recovery
In early recovery and working to rebuild my life
Stable in recovery but feeling stuck in other areas
In a life transition and looking for deeper support
Other
What areas of your life are you most wanting to improve right now?
*
Emotional wellness
Energy
Daily structure/routine
Confidence
Identity/purpose
Relationships
Boundaries
Physical wellness
Hormone-related wellness support
Spiritual growth
Other
Where do you currently feel most stuck?
*
What kind of support are you looking for at this stage of your life and recovery?
*
Readiness and Fit
What makes you feel this mentorship may be what you are looking for right now?
*
On a scale of 1 to 5, how committed are you to making meaningful changes in your life at this time?
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Thinking about it
1
2
3
4
Willing to do whatever it takes
5
1 is Thinking about it, 5 is Willing to do whatever it takes
What does restoration mean to you personally right now?
*
Are you willing and able to invest time, energy, and financial resources into your growth and restoration at this stage?
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Yes
Possibly, depending on the program fit
Not sure yet
Current Support System
Are you currently working with any of the following support professionals?
*
Therapist
Counselor
Sponsor
Recovery coach
Primary care provider
Psychiatrist
None at this time
Other
If applicable, please tell me a little about the support professionals you are currently working with and their role in your life.
Final Thoughts
Is there anything else you would like me to know before we speak?
Submit Application
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