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Form for counselors or therapists who use Relief for Hurting Parents
and/or Teens Fight Adult Corruption in counseling or therapy...
Please complete as much of the following form as possible. If you do not want
specific information disclosed, please indicate which items in the additional comment
area.
Name of Organization or Business:
Statement of Purpose:
Mailing Address:
City:
State or Province:
Zip:
Physical Address (if different):
City:
State or Province:
Zip:
Country:
Near what landmark:
E-mail:
Web Page:
Director's Name:
E-mail:
Counselor's Name (1):
E-mail:
Counselor's Name (2):
E-mail:
Counselor's Name (3):
E-mail:
Does your counselor(s) qualify to counsel readers of Relief for Hurting Parents in harmony with the basics of the guidelines for choosing a counselor in chapter 23 or Relief?
Yes No
Fee Structure:
Will the counselor(s) counsel over the phone if clients pay an in-office fee and the long-distance charges (if any)?
Yes No
Business Hours:
Time Zone:
Business Days:
Contact Person:
Contact Phone Number: Best time to call:
I/We use Relief for Hurting Parents and/or Teens Fight Adult Corruption when working with clients.
The following section applies only to those agencies sponsoring support groups and/or parenting classes.
Which best describes your organizaiton:
group
class
both
Facilitator(s):
Meeting time:
Meeting day:
Duration of meeting:
Does your group or class use Relief as the primary text as required?
Yes No
Can new parents, grandparents, or guardians start at any time?
Yes No
Is there a volunteer a new parent, grandparent, or guardian can call for support between meetings?
Yes No
If yes:
First Name: Last Name:
Address:
City:
State or Province: Zip:
Primary phone number: Best time to call:
Alternate phone number: Best time to call:
E-mail:
Additional information or comments:
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