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Personal Details *

First Name

Last Name

Date of Birth

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DD

YYYY

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Phone

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What brings you to Epic Comeback?

Divorce

Diagnosis

Devastation/Loss

Have you worked with any of these resources?

Individual Therapy

Group Therapy

Support Groups

Physician/Medication Management

Life Coaching

Other

Are you currently seeing a therapist?

Yes

No

Do you have any chronic health conditions?

Yes

No

Do you have any physical limitations?

Yes

No

Many of our scholarship resources require the following from recipients:

- Completion of growth assignments and self-reflection - Active participation in your reinvention story - Partial payment based on the scholarship you receive

I can commit to these requirements

I cannot commit to these requirements

Epic Comeback Pledge

The "EPIC COMEBACK" pledge is essential for personal reinvention—it's your roadmap to healing and growth. When you commit to this pledge, you're not just transforming yourself; you're elevating everyone around you. Just like a rising tide raises all ships, your journey of positive change has a profound impact, spreading waves of encouragement and strength throughout your community. It’s about lighting up your corner of the world, and watching that light spread, fostering a network of support and resilience that benefits us all. Do you agree (with support) to keep this pledge? 1. Take responsibility for my growth and healing 2. Be present and engaged in the program 3. Contribute positively to the Epic Comeback Community 4. Use challenges as opportunities for growth 5. Support others with empathy and understanding 6. Take ownership of my choices and actions 7. Maintain hope and determination 8. Actively participate in my transformation

I agree to uphold the Epic Comeback Pledge

Consent and Privacy

I understand this information is confidential and protected

I agree to receive communications from Epic Comeback

I consent to the verification of the information provided

I have reviewed the privacy policy [See below the submit button]

Epic Comeback is a non-profit organization that assists survivors in reinventing themselves after loss or tragedy. We are not direct providers of these services; rather, we are a conduit of support to help match those who are ready and willing to take an active role in their own reinvention with key resources who act as points of light on the path toward recovery.

I understand

Epic Comeback is NOT an emergency services provider or a crisis-receiving program. If you need immediate assistance, please call 911 or utilize these Emergency Resources: 988 Suicide and Crisis Life Line: Dial or Text 988 Warmline (for a friendly person to talk to): 1-855-845-7415 SAMHSA's Disaster Distress Line: 1-800-985-5990 or text TalkWithUs to 66746

I understand