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Contact Information
Are you in need of domestic violence services?
* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone Number
*
Your answer
Are you in domestic violence right now?
*
Yes
No
I'm not sure
What services are you interested in? This is for individual services.
*
Survivor Guide, Domestic Violence Classes- 12 classes- $1,500
Trauma Informed Education/Counseling 12 weeks- $1,500
Empowering beyond abuse- 12 classes $1,500
Other:
Are you in need of a sliding scale? (Proof of income must be provided.
*
Yes, I need a partial scholarship/I'm able to pay a portion of the fee
No, I can pay for the full service.
Required
If requesting for a sliding scale your consultation fee would be $30. If you aren't able to pay this amount, please state what amount you are able to pay for the consultation.
Your answer
Documentation to provide proof of hardship. Any of these:
Pay Check stub
Shelter contract
Police Report
Medical Records
DPSS award letter
SSI
Other:
Clear selection
Did you submit proof?
Choose
Yes
I need more time to gather them
How will you be paying for services? (ZELLE or Paypal)
*
Your answer
Best Day to meet
*
Mon
Tue
Wed
Thur
Fri
Sat
Morning 11-1
Afternoon 2-4 PM
Evening 5-7 PM
Mon
Tue
Wed
Thur
Fri
Sat
Morning 11-1
Afternoon 2-4 PM
Evening 5-7 PM
If the above times don't work, we can work around your schedule
Your answer
This is for group or class facilitation.
A separate price list will be sentÂ
Are you interested in hosting a trauma informed psychoeducation domestic violence group?
Survivor Guide, Domestic Violence Classes- 12 classes
Pathways to Healing-12 classes
Clear selection
How did you hear us?
Your answer
Send me a copy of my responses.
Submit
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