Restore Therapy Collective

After submitting this form, a Restore Therapy Collective team member will contact you via encrypted email. Please be sure to check your spam folder. In order to view the response, you will be prompted to sign into a Hushmail portal to ensure confidentiality. If you have questions, please call our office at 616-228-9244.

If this is an emergency, please go directly to your local emergency room or call 911. You can also contact the Pine Rest Urgent Care Clinic if you are near the Grand Rapids area.

First name

Last name

Email address

Phone number

Restore can contact me by: (check all that apply)

Phone

If you selected "Other health insurance", please indicate what health insurance policy you hope to use:

Please select the services you are interested in:

Individual Therapy

Couple Therapy

Family Therapy

Both Individual & Couple/Family

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Your information will be encrypted.

After submitting this form, a Restore Therapy Collective team member will contact you via encrypted email. Please be sure to check your spam folder. In order to view the response, you will be prompted to sign into a Hushmail portal to ensure confidentiality. If you have questions, please call our office at 616-228-9244.

If this is an emergency, please go directly to your local emergency room or call 911. You can also contact the Pine Rest Urgent Care Clinic if you are near the Grand Rapids area.