I Am My Sister's Keeper Program Intake Form

Welcome

Welcome to our Empowerment Holistic Mentorship Program! We are honored to support you on your journey towards healing and empowerment. Our program is designed to provide a safe, compassionate, and supportive environment where you can find the resources, guidance, and community you need. By enrolling, you are taking a courageous first step towards reclaiming your strength and building a brighter future for you and your family. Welcome, we are your starting point.
Our Policy!

The completion of this form does not guarantee that you are going to receive assistance from the Thee Blueprint Collective nor our participating partners or collaborators. THERE ARE REQUIREMENTS THAT PARTICIPANTS MUST MEET AND OBIDE BY SUFFICIENTLY FROM ALL PARTIES INVOLVED IN ORDER TO BE ASSISTED. If you do not meet the qualifications for this year, you may enroll again next year. If you meet the qualifications and start the program but deter from the requirements, you will be dropped from the program effective immediately, loose all benefits, and will be notified by email.

We look forward to the journey ahead. See you soon.
Sign here to indicate that you have read the statement above, understand, and agree to the terms. *

Powered by Jotform SignClear
Name*

First NameLast Name
Email*
example@example.com
Date Of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What inspired you to join the Sisters Keeper Program?*
Please share with us your survivor story.*
What are your goals or aspirations for participating in the program?*
Have you participated in any similar programs or support groups in the past? If so, what was your experience like?*
Are there any specific topics or areas of focus that you would like the program to cover?*
How do you envision yourself contributing to the program and supporting other survivors in their healing journey?*
What county do you live in?*
What is your relationship status?*

SingleWidowedMarriedComplicated
How many children do you have?*
Which best describes your personality? Choose one*

IntrovertExtrovert
How would you describe yourself?*

BraveAffectionateAmbitiousParty StarterPeacemakerAtheleticIndependantForgivingSupportiveConfidentTrustworthyFaith BelieverPatientCompassionateMotivatorSpiritual
What services / resources are you seeking?

Drug and alcohol abuseDomestic ViolenceBreast HealthWeight LossWeight GainSelf ConfidenceEmpowermentHygienceSexual AbuseDepressionType option 2Type option 3Type option 4
Which wellness community are you interested in joining? You must be active in at least 3 communities per month to qualify. If there is no activities being held in the community you have chosen, no actions will be held against you.*

SocialintellectualPhysicalSpiritualEmotionalFinanceEnvironmentalOccupational
Which do you prefer for your community experience? Choose one.*

MorningsAfternoon
Which do you prefer for your community experience? Choose one.*

WeekendWeekdays
Are you apart of other programs or organizations? If yes, list them below, along with a brief sumary of your experience and how long you have been apart of said program?*
As a participant, you will be required to help raise funds which will assist with the activities for the program. Are you great at fundraising? If yes, list some fundraisers that you would like for us to hold for the program. *
Upon completion of the Sister's program, would you be interested in becoming a mentor for another survivor? If yes, you will be contact by an admin from our office to discuss more in details. Thank you.
Are you currently employed, if yes where and what is your position? *
Do you have an insurance provider? if yes, what is the name of the insurance and is it current? *
What do you hope to gain from interacting with other survivors in the program?
Upon completion of the program, if you feel like you are ready to take your next steps, would you like therapist referrals?*

YesNo
DISCLAIMER:

It is important to understand that Thee Blueprint Collective nor our partners or collaborators are liable for any successes or failures that may arise from enrolling in our program. We work hard to ensure that our communities are comprehensive and impactful, but ultimately, each individual is responsible for their own growth, success, and overall outcome. We recommend that each individual take our program seriously, put in the time and effort necessary to excel, and seek additional resources and support as needed. Thank you.
Signature*

Powered by Jotform SignClear
Should be Empty:

Welcome