Sponsorship recommendation — Gracefully Broken, Inc

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Your gift to us is the ability to see others!

Recommendations are not guaranteed sponsorship, however we are working tirelessly to ensure that 25 women are sponsored. If you would like to donate towards or sponsor a lady, click here.

Today's Date

MM

DD

YYYY

Recipients Name *

First Name

Last Name

Email *

Phone

(###)

###

####

How do you know this person?

Is this individual actively engaged in efforts to improve their mental health and overall well-being?

Yes

No

Unsure

If yes, please briefly describe the specific actions or practices the individual is currently undertaking:

Do you believe the individual would benefit from a reset through participation in a wellness retreat? *

Please provide any additional comments or observations that may assist in evaluating the individual's suitability for a wellness retreat: *

Overall, without violating HIPAA, how would you rate the individual's current mental health status?

Excellent

Good

Fair

Poor

Unsure/ Will not disclose

Are you a licensed professional?

Yes

No

Your Name *

First Name

Last Name

Your Email (Must Be Verifiable Business Email)

CANNOT BE GMAIL, YAHOO or other personal email carriers; can be website or business name with number to verify

Thank You for your input. Your feedback is valuable in supporting the individual's journey towards improved mental health.

Thank you!