Restoration Application

SECTION 1

Personal Details

Please complete the information below so that your Restoration Intake can be reviewed.

Full Name *

Preferred Name

Date of Birth *

Age *

Email Address *

Mobile Number *

City *

Province / State *

Country *

Who is this Restoration Intake for? *MyselfMy DaughterA Young Lady in My Care

If completing this intake on behalf of someone else, please provide her name and age.

SECTION 2

Your Season of Life

This section helps us understand where you are in your present season and how best to support you.

Do you have children? *YesNo

If yes, how many?

Occupation

SECTION 3

Areas You Would Like to Restore

Please select the areas you would like your Restoration Intake to focus on.

Select all that apply.

Is there anything else you would like to restore or receive support with?

SECTION 4

Tell Us More

The questions below provide additional context as your Restoration Intake is reviewed.

1. What would you most like to experience through your restoration? *

3. Is there anything you feel may have contributed to this?Optional

4. Have you previously received support for this area? *NoYes, through professional supportYes, through personal studyYes, through faith-based guidanceOther

5. If you wish, please tell us briefly about your experience.

6. Is there anything else you would like me to know as your Restoration Intake is reviewed?

SECTION 5

Restoration Preference

Based on what you know at this stage, which option are you most interested in?

This selection simply lets me know your current preference. Every Restoration Intake is individually reviewed before a personalised recommendation is prepared. The pathway you initially express interest in may be adjusted where another option is considered more appropriate.

Mapping & Restoration Containers *2-Week Focused Restoration Container — R2,9504-Week Deep Restoration Container — R4,9506-Week Comprehensive Restoration Container — R6,95055-Minute Private Restoration Session — R55080-Minute Private Restoration Session — R800110-Minute Private Restoration Session — R1,000I'm unsure which option would be most appropriate and would appreciate a personalised recommendation.

Preferred Session Format *Please select one option.OnlineIn Person (where available)No Preference

Preferred Time of Day *Please select one option.MorningAfternoonEvening (where available)

SECTION 6

Declaration & Consent

Before submitting your Restoration Intake, please read and confirm the following:

I confirm that the information I have provided is true and accurate to the best of my knowledge.I understand that submitting this Restoration Intake does not create a booking or reserve an appointment.I understand that my Restoration Intake will be reviewed before a personalised recommendation is prepared.I understand that my personalised recommendation is based on the information I have shared within this Restoration Intake.I understand that payment is only requested after I have reviewed and accepted my personalised recommendation.I have read and agree to the Client Agreement.I have read and agree to the Privacy Policy.I have read and agree to the Cancellation & Rescheduling Policy.I have read and understand the Scope of Practice.

Submit Your Restoration Intake

When you are ready, click the button below to submit your Restoration Intake.