Participant Support Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Apartment / Unit

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Gender

Race

Do you Identify as LGBTQIA+?

Current Living Situation

Do you feel safe where you are currently living?

Are you Married?

Alternate Number

What kind of support are you seeking today? (Check all that apply)

Please list the problem(s) which you are seeking help? Please don't include medical conditions / information or diagnosis on this form.

Do you have a support system?

YesNo

Do you have children or dependents living with you?

YesNo

What is your most immediate / important need at this time? What's the Priority?*

Name, Age, Gender and Relation of all children in your care or household

Who? How old? How are you related?

On a scale of 1 to 10, how do you feel about your life right now? ( 1 = really struggling, 10 = feeling strong and hopeful)

Have you ever been charged with a crime?

YesNo

If yes, Please list charges, sentences or outcomes.

Has anyone in your family been diagnosed with or treated for:

Do you exercise regularly?

YesNo

Current Weight

Current Height

How much time each day do you exercise?

Check if you have ever tried the following

Are you currently using any drugs?

How many years?

Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.

Highest grade completed?

Are you currently:

Additional information

Emergency Contact

First NameLast Name

Phone Number

Please read the following carefully. By signing this agreement, you acknowledge and accept the terms of participation:

1. Voluntary Participation

I understand that all services, programs, workshops, and peer-led sessions provided by Home for Healing / The Impact Center are offered on a voluntary basis. My participation is my choice and I may withdraw at any time. I also understand that Home for Healing / The Impact Center reserves the right to discontinue or terminate my participation at anytime.

2. Nature of Services

I understand that the services provided are non-clinical and do not include medical, psychiatric, or liscensed mental health treatment. These services may include but are not limited to:

Peer Support (Non Clinical)
Resource Navigation
Group Sessions and Community Events
Wellness Coaching
Workforce and housing-related supports
Referrals to Community based services

3. No Guaranteed Outcomes

I understand that participation in services doesnot guarantee any specific outcome, including:

Access to housing
Acceptanceinto finacial or public assistance programs
Employment or income
Medical, legal, or social benefits

Home for Healing / The Impact Center offers support, tools and referrals, b ut has no control over the decisions of outside agencies or partners.

4. Children in the Space

Children are welcome at The Impact Center, and we are proud to serve whole families. However to ensure a safe and supportive enviorment for all:
Children must remain under the direct supervision of their parent or guardian at all times
Parents / guardians are expected to maintain their child's behavior while on site / in or outside the building
Disruptive or disrespectful behavior or lack of adequate supervision may result in the participant being asked to leave and or / removal from the site.

5. Personal Responsibility

I agree to participate with a spirit of honesty, openmindedness and willingness. I understand that I am responsible for my own decisions, wellbeing, and outcomes, and that my growth requires my participation

6.Confidentiality

We take confidentiality very seriously in order to protect the dignity and safety or every participant.

I understand that by participating in services I agree to:

Keep what is shared by others private and confidential
Avoid discussing other participants' stories or situations outside of this space

In short: What's shared/happens here STAYS HERE.

We will not share your information unless:

You express intent to harm myself or others
There is a disclosure of abuse or neglect
You provide written consent to share information with another party

7. Assumption of Risk & Release of Liability

I understand that participation in any group, activity event, or service may cary inherent risks, including emotional, mental or physical responses. I hereby release and hold harmless Home for Healing / The Impact Center from any and all liability as outlined above.

8. Acknowledgment & Signature

I have read and understand the nature of the programs and the terms of this agreement. I understand that this is an at-will engagement and that either party- myself or Home for Healing/ The Impact Center may end participation at any time.

Signature*

Date

Participant Support Form

Liability Waiver & Participant Agreement