• Participant Release Agreement & Confidential Intake Form

  • Deeper Still is a program including healing retreats for women and men who have undergone or participated in an abortion procedure (the "Program"). The Program is specifically designed to address the healing of emotional and spiritual wounds associated with abortion. 

    Deeper Still retreats are hosted by a team of volunteers ("Team Members") who have received para-professional training to assist attendees in the healing process within the context of the Program. Participation by attendees in Deeper Still retreats or any associated function(s) is not intended as a substitute for professional counseling and/or medical treatment.

    By signing this agreement form, I freely and volunteerily agree with and understand the following statements to be true and I hereby agree to bind myself to such statements in consideration for the opportunity to participate as an attendee of an upcoming Deeper Still retreat.

    • The Team Members are volunteers and not licensed professional counselors.
    • The Team Members are not giving medical advice, making diagnoses, or providing licensed professional counseling.
    • I will not hold Deeper Still, the Team Members, or other persons or entities directly associated with Deeper Still responsible for my actions or the actions of others made in response to any teaching, advice, ministry, or any other goods or services I may obtain at a Deeper Still function.
    • I fully release Deeper Still, the Team Members and/or persons/entities directly associated with them from all liability whatsoever.
    • I assume full personal responsibility for any financial obligation I understand based on and/or in response to any teaching, advice, ministry, or any other goods and/or services I may obtain at a Deeper Still function.
    • Information I give to any Team Member will remain confidential. There will be no sharing photos or videos of me publically or on social media without my permission. However, I also understand exceptions to such confidentiality include:
      • any situation in which I communicate I am considering physically harming myself or another person,
      • any situation in which I communicate another person is continuing to or has expressed his/her intent to physically harm me, and/or
      • any situation in which a formal grievance is brought against Deeper Still, the Team Members and/or persons/entities directly associated with them.
      • any situation in which I communicate I am presently involved in illegal activity.
    • I agree to honor the code of confidentiality of Deeper Still to not disclose personal information shared by other retreat participants without their permission.
    • Any formal grievance brought against Deeper Still, the Team Members and/or persons/entities directly associated with them are to be decided under Tennessee law and, if litigation ensues, in Tennessee courts of law in the Eastern District of Tennessee--the state and federal courts in which are deemed a proper venue by the undersigned for any such action--wherein such courts, based on this agreement, shall have personal jurisdiction over the undersigned.
    • If any part of this agreement is deemed void by a court of law, the other portions of the agreement will remain in full force and effect.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Confidential Intake Form

    IMPORTANT: Due to content sensitivity, this form CANNOT be saved to finish later. Once you begin, it must be completed.
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred Date of Deeper Still Pikes Peak Retreat
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Below is a list of potential symptoms/feelings that you may have experienced as a result of or since your abortion. Check all that apply.

  • Pregnancy and Abortion History

  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at that time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?
  • Approximate Date of Event
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was your marital status at the time?

  • Religion / Spiritual

  • The following are various ways of describing your experience with God. Check any that may best describe yourself (You may check more than one.)
  • Format: (000) 000-0000.

  • This completes our intake form. Please know that your information is respected and will be kept confidential. You have been prayed for long before you ever filled out this form. See you at a retreat!

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