Confessional Community Clinical Training Program Application Form

The Confessional Community Clinical Training Program™ Application Form
Personal Information
Please be aware that communicating personal information electronically poses a risk to your confidentiality. New Story Staff will not disclose any personal information provided on this application form.
Full Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Text Messaging Opt-In (SMS Opt-in). If you wish to receive text messages from New Story Behavioral Health, including your clinician, please select the appropriate option below:
We would like to keep you informed of events and services offered by New Story Behavioral Health. Check here to consent to receiving information via email. Emails will be sent to your inbox as standard, unsecured (unencrypted) email. Please take appropriate care to protect your personal privacy. You can unsubscribe from emails at any time.

Yes, keep me informed.No, thank you.

Photo/Video Image Release:

New Story Behavioral Health reserves the right to photograph and record videos of large group teaching sessions during the Opening and Closing Events. Photos and videos captured during these times will be used for promotional purposes for future training events, including but not limited to print media, website, and social media. The identity of persons in images or videos that are not employed by New Story Behavioral Health will not be released. Anyone who chooses not to have their image distributed should make their wishes known via email to events@newstorybh.com. Such email should include a photo for identification purposes and will be held confidential.
I have read and agree to the above photo/video image release:*

Yes, I agree
Notice of Observers

New Story Behavioral Health invites qualified individuals to participate as silent observers of the Confessional Community Training Program™, including but not limited to large group teaching and in-person and virtual Confessional Communities™. These observers are present to observe group leaders and learn the skills necessary to successfully lead Confessional Communities™.
I have read and agree to the notice of observers during the Training Program:*

Yes, I agree.
Disclaimers and Notices:

The Confessional Community Clinical Training Program ("Program"), provided by New Story Behavioral Health (“New Story”), is educational and consultative in nature and does not constitute mental health treatment. Participants should not consider participation in the Program, or any of its events, as a substitute for mental health treatment. Participants in need of mental health referrals or treatment should contact New Story staff to request assistance.

Participants in the Program understand that conversations and interactions in the context of interpersonal groups may, at times, produce emotional discomfort (e.g. anxiety). Participants acknowledge and accept this risk and are reasonably confident in their ability to tolerate emotional discomfort. Participants agree to discuss any mental health concerns with a staff member before participating in the Program. Mental health concerns that warrant discussion include but are not limited to: active addictions; psychotic episodes; panic attacks; or persistent emotional dysregulation. New Story staff members may, at their discretion, at any time, suspend a participant’s participation in the Program, or its events, if there are concerns about the participant’s or other participants’ safety or well-being.

Participants agree to maintain strict confidentiality both during and after Program events. Confidentiality includes not disclosing identifying information or personal content shared by other participants.

Participants may not reproduce any written or digital material obtained from New Story without written permission.

Participation in the Program is by application only. Applicants must complete this application form and participate in a screening appointment with a New Story staff member. Acceptance of participation in the Program is not guaranteed regardless of an applicant’s previous experience with New Story. Acceptance of participation in the Program does not guarantee acceptance as a patient at New Story or imply that accepted participants will be able to receive mental health treatment at New Story at any time. Acceptance of participation in the Program does not guarantee acceptance to subsequent programs, events, or services at New Story.
I have read and agree to the above disclaimers and notices.*

Yes, I agree
Should be Empty:

The Confessional Community Clinical Training Program™ Application Form

Personal Information

Application Information