Trauma Healing Cohort 6 Month Application

EmpowerHER Application

Section 1: Personal Information

1 Full Name

2 Email Address

example@example.com

3. Phone Number

4. Age

5. Gender

FemaleMale

6. Location City State Country

Section 2: Background Information

1. Please describe your current life situation (eg work, family, relationships, etc.)

2. What inspired you to apply for the EmpowerHER?

3. Have you participated in any trauma healing or mental health programs before?

If yes please describe your experience (or reply NA)

Is there someone you'd like to request as a roommate for the retreat weekend? Please include their full name if possible. We will do our best to accommodate your request. If no, please write NA.

1. Have you ever been diagnosed with any mental health conditions?

YesNo

If yes, please provide information such as diagnosis, treatment, and current status. If not applicable, please write NA

2. Do you currently receive mental health care (e.g. therapy, counseling, pastoral)?

YesNo

3. If yes to above question, would you be okay with us reaching out to your mental health provider, pastor, or mentor—if you have one—just to help us better support you? This would only be done with permission to better coordinate your care. If this question does not apply to you, please select NA option.

YesNoNA

4. Have you ever experienced trauma (physical, emotional, sexual, etc.)?

YesNo

If yes, please briefly describe how the trauma(s) have impacted your life. If this does not apply to you, please write NA.

5. What are your primary goals for healing and personal growth during this program

6. Do you now, or have you ever experienced challenges with substance use or addictions (substance or otherwise)?

YesNo

If yes, please describe your history with substance use or addiction, including anything you may have struggled with currently and/ or previously. If no, please reply NA.

Section 4: Willingness & Participation

1. Are you committed to attending the entire in person retreat (refer to website for dates), all virtual sessions, and completing the 16 week program?

YesNo

2. This program requires active participation in discussions, group activities, and healing exercises. Are you willing to engage fully?

YesNo

3. Are you open to receiving mentorship and feedback from program coaches and the other participants?

YesNo

4. The program's success depends on your ability to be consistent and committed. Can you commit to maintaining regular communication and following the Participant Guidelines of the program located on the ministry website?

YesNo

5. Please confirm that you understand that failure to comply with the program's guidelines may result in removal from the group, and that completion of the program requires full participation.

YesNo

Section 6: About You

1. Describe any strengths or skills that you feel will help you in your healing journey.

2. What are some challenges or obstacles you anticipate during the program.

3. Please share any additional information that you believe is important for us to know about you.

4. What patterns or dynamics do you notice in your relationships over time?

5. How do you typically navigate conflict or emotional distance in your relationships?

6. Do you experience emotional closeness in your relationships?

YesNoUnsure

Section 5: Financial Responsibility

1. Are you financially able to cover the cost of the program?

YesNo

2. If no to question 1, please select from the following, or select NA if this does not apply to your previous answer:

I will use A Ministry of Presence Sponsorship letter to attain funding from my church, sphere of influence, or another organization (refer to website).I will utilize the fundraising tools from outside source or from A Ministry of Presence to cover the cost of the program (refer to website).I will utilize both of the recommended tools to raise funds.I will contact A Ministry of Presence for tax deductible donation letters.NA

3. By initialing below, I understand that if I am unable to attain the necessary funding, I must inform A Ministry of Presence for next steps as soon as possible.

4. By initialing below, I agree that I have read and understand the EmpowerHER financial guidelines. I further understand that upon receiving my acceptance email into EmpowerHER, a 50% deposit is due within two (2) business days, or I may loose my place in the program. I further acknowledge that failure to settle the remaining balance two (2) weeks prior to start date may result in loosing my placement in the program. Any failure to make payment(s) by deadline will result in excusal of the program, and no refund will be issued.

5. By initialing below, I acknowledge that I may be placed on a waitlist for the EmpowerHER program, and that if I am accepted, I understand there may be a consolidated timeline for paying program costs. I agree to adhere to the payment schedule provided upon my acceptance into the program.

Section 7: Program Understanding & Agreement

1. Our facilitators have a diverse background in providing pastoral- care and certifications for trauma informed care. However, the facilitators and mentors in this program are not licensed mental health professionals. The program focuses on trauma healing through mentorship, support, and personal growth within a faith-based framework. I understand and agree.

Please Initial

2. I acknowledge that this program is rooted in Christian principles and incorporates the guidance of the Holy Spirit, along with faith-based practices, and current mental health exercies as part of its approach to supporting participants in the healing process.

Please Initial

3. I understand that acceptance into the program will be based on my responses, and I may be contacted for clarification prior to being accepted.

Please Initial

4. By initialing below, I agree that I have read and understand the Participant Guidelines that can be found on A Ministry of Presence website.

Please initial

5. I understand that not complying with Participant Guidlines (refer to website) throughout the length of the program can result in excusal. I further understand that any finacial payments made will not be refunded.

Please Initial

6. I acknowledge that facilitators within this program may discuss my progress and any relevant concerns among themselves, as necessary, to ensure effective coordination and to provide the highest level of support for my participation in the program.

Please Initial

7. I confirm that all information provided in this application is accurate and truthful.

Please initial

Thank you for completing the application We appreciate your willingness to engage in this important healing journey A member of our team will be in touch with you soon.

Section 3: Mental Health& Trauma History