Freedom Beyond Abuse Application - Grace's Place Foundation

Please fill out this short application and include any additional information you feel you want to share with us. We will be following up with a phone conversation to get to know each other better before the program begins.

Are you in immediate danger?

Yes No

Are you currently living with your abuser?

Yes No

If not, how long have you been away from your abuser? 1 month to 10 years. Please specify.

Do you have any additional support at this time?

Yes No

Are you ready to receive support to move forward in your life?

Yes No

Are you available Thursday evenings?

Yes No

Do you have a computer or smart phone with internet access?

Yes No

Are you willing to commit a year to yourself and your future?

Yes No

Name

Address

Phone Number

Email Address

Please add any additional information you want to share here.