1:1 Emerald Journey Mentorship Program Assessment

The Emerald Journey is a trauma informed virtual mentorship program empowering survivors to heal from sexual trauma through the hope, healing, and freedom found in Jesus Christ!

During this assessment session we will discuss your goals and eligibility for the Emerald Journey Mentorship/Coaching Program.

You will receive an email with a link to schedule your 1:1 zoom video assessment session upon the submission of this form. This meeting will take place with the program director and at times an intern coordinator may assist in the call.

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Emerald of the Sea is a faith based Non-profit whose mission is to Encourage,Empower, & Educate others through sexual trauma recovery & prevention. www.emeraldofthesea.org

Name

Mailing Address

This address will receive a confirmation email

Phone

I verify that I "participant" am at least 18 years old or older.

Is there anything you would like me to know about you prior to meeting?

Waiver of Release & Memo of Understanding

Please sign or inital the following:

I release Emerald of the Sea of any and all liability and hereby waive any and all rights, claims, or causes of action of any kind arising out of my participation in any event or session hosted by Emerald of the Sea.

MEMO OF UNDERSTANDING

I understand that Emerald of the Sea's leadership team is morally and ethically obligated to discuss with me any of the following behaviors, and that this may lead to breaking of confidentiality and/or possibly intervention:

I communicate anything that may be interpreted as a threat to self-inflict physical harmfuI communicate an intention to harm another person

I reveal ongoing sexual or physical abuse

I reveal that I have perpetrated an act of child abuse and/or child molestation

I have expressed the intent to commit such an act

I reveal that I have perpetrated or am considering an abusive act toward the elderly and/or disabled

I have been advised that the consequences for communicating the above types of information may include reports to the proper authorities: the police, suicide units, or children's protective agencies, as well as to any potential victims.

I further acknowledge that if I am on probation and/or parole and I engage in wrongful behavior in violation of my parole/probation, part of my healing/recovery may include notifying the appropriate authorities.

I understand that this is a Christ-centered mentorship/coaching program that integrates recovery tools with the Bible and prayer.

I realize that the Bible may be discussed more (or less) than I would like it to be.

I fully read and understood the waiver of release and memo of understanding above. SIGNATURE REQUIRED

Comments/Questions

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1:1 Emerald Journey Mentorship Program Assessment

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