Inquiries About Reconnection

If you are interested in applying for help with reconnection, it is important that you provide the following information detail. Incomplete forms will be set aside for further information.

Name (required)

Address (required)

Phone (required)

Email (required)

1. How did you hear about the JAYC Foundation?

2. What precipitated your contact with the Foundation? challenge?

3. What are the issues that you would like help with?

4. Please provide a brief description of how you think the Foundation can help your family?

5. Have you or any member of your family been in psychotherapy or counseling before?
If so, When, with whom, and for how long?

6. What is the current custody arrangement of any minor children?

7. Please list the members of your family to be included. Please list name, age, and relationship of each.

If you are interested in including family members who are adults, please let us know the likelihood of their willing participation.

8. Are there other agencies or professionals involved at this time? Family Court? CPS? Law Enforcement? Attorneys? Others?

9. Do you have a community social worker, therapist, or Victim Witness advocate helping you at this time? If so, who? (please include contact information)

10. Are you able/willing to travel to access our services?