Stand Up Survivor One-on-One Counseling
Thank you for your interest in obtaining CONFIDENTIAL one-on-one counseling services from Stand Up Survivor.  Our one-on-one counseling sessions are provided by a Registered Clinical Social Work Intern or a Master's of Social Work (MSW) intern; these sessions will be personalized to your needs and meet you were you are on your healing journey.
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What's today's date? *
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What is your name (first and last)? *
What's your email address? *
What is your phone number?
Are you safe from your abuser? *
How long have you been safe (months/years)? *
What healing modalities have you tried/do you use? *
Required
If you chose other, please explain
If you've done counseling, how long did you do it for? Did you find it helpful? Why or why not? *
Do you live in the State of Florida? *
Do you live in Orange County, Florida? *
I understand that, if chosen, I will be contacted withing 48 hours. *
These sessions are given free of charge, to you the client.  If you miss two sessions without communicating appropriately, you will be discharged from services and your slot will be given to another client. *
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