Participation Form

Participation Form

"Empowering Minds, Nurturing Souls: Transforming lives!"
Reprieve Us Again Global Impact is a 501c3 ministry:

Mission:

Our mission is to provide mental health wellness support and mental respite through education, training, resources, and community outreach.

Vision:

Unlocking Minds and Restoring the Soul!

·Restorative coaching group helps to guide individuals with effective strategies used to enhance mental clarity and spiritual care. This approach is a combination of psycho educate, group therapeutic modality, and spiritual care/support.

Disclaimer: Services offered are not a replacement for therapy but a supplemental mental wellness support with spiritual care component. Please be advised that participation in services is voluntary and this is not a commitment of acceptance or continuation of services. Limited slots available may result in early termination or a pause it services. There is no guarantee of requested time slots and some programs are contingent upon funding and availability.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age
Gender
Please share with us how you feel you can benefit from the services selected.
Do you have any past traumatic experiences or mental health diagnosis(s)?
Signature
Due to the sensitivity of some discussions RUA Global Impact reserves the right to divide groups when appropriate. This may include dividing groups by gender or gender identity. Please state any preferences below 👇.
Preference
Confidential disclosure
This is a closed group. Please keep all participation confidential, use a private/confidential space, and do not take screenshots or make audio/video recordings.
Agreement Signature

Please sign to confirm your agreement.
Should be Empty:

Participation Form

Confidential disclosure