Please take the time to fill out the form below. The information that we obtain in this form is confidential. This will help us to understand more about you and how we can support you along your restoration journey.

Restoration Program Intake Form

First Name

Age

Last Name

Phone

Street Address

City

Postal / Zip code

Street Address Line 2

Region/State/Province

Approximate Date of Abortion

Age at the time of abortion

At the time, who knew about the abortion?

Overall, how do you feel you are coping since you had the abortion? On a scale of one to ten select the number that describes how well you are coping. 1 being not coping well and 10 coping really well

Other

If you checked that you are experiencing suicidal thoughts please contact the Suicidal & Crisis lifeline Hotline at 988 or go to your nearest hospital

Please describe how experiencing these symptoms has affected your day to day life

Has the way you viewed yourself changed after having the abortion? If so, how do you view yourself now?

Do you believe in God? If so, how has your relationship with God been affected? Are you having a difficult time receiving His forgiveness?

Have you sought out any resources previously to assist with healing from having the abortion? If so, what resources did you seek? How effective were they in helping you?

Please state what you hope to achieve through the restoration program. How can we best support you during your restoration journey?

Is there anyone that you would like to refer to the program? If so, please provide their contact information ( First name, last name, phone number or email)

Thank you for taking the time to fill out the form! Our team will review your form and get back to you within 5 business days to let you know the next steps. At this time, each support group can have up to 5 women. In the event, that the program is full we will place you on a waitlist and will reach out to you during the next enrollment period.

Thank you for your interest in the post-abortion restoration program. At this time our registration is closed. Please reach out to us at info@arukahrestores.org if you would like to be put on the waitlist for the next enrollment period.

Restoration Program Intake Form

Stay Connected with Us