Ministry Retreat

Pre-Assessment Form

THE TRIAGE ROOM™ – CONFIDENTIAL LEADERSHIP DIAGNOSTIC

This assessment is not a performance evaluation. This is not disciplinary. This is not used for ranking or comparison. It is used to: • Identify leadership strengths • Detect stress patterns • Clarify alignment • Design targeted retreat workshops.

Your honesty helps strengthen the entire leadership culture.

THE TRIAGE ROOM™
Leadership Intensive Consent

&

Participation Agreement
Assess | Stabilize | Treat

FACILITATOR QUALIFICATIONS
This intensive is facilitated by:

Dr. Jason D. Green, Ed.D.
Doctor of Education and Honorary Doctorate of Christian Counseling (Saint of Value MTC)
Board Certified & Licensed Christian Counselor (NACC)
Board Certified & Licensed Chaplain (Grace School of Seminary & Chaplaincy/SDBCA)
Chancellor, Man of War Ministry School of Seminary & Chaplaincy
Ordained and Affirmed Apostle & Prophet.                                                             
Founder, The Triage Room™
Qualified in Crisis Intervention and Trauma-Informed Care

Dr. Green is trained in:

• Crisis intervention and stabilization
• Trauma-informed leadership systems
• Emotional regulation and conflict stabilization
• Organizational recalibration within professional,corporate, and ministry settings
• Christian counseling frameworks

This leadership intensive operates within professional, ethical, and ministry-based standards of care.

PURPOSE OF THIS INTENSIVE
The Triage Room™ Leadership Intensive is a structured leadership development and organizational health initiative grounded in the model:

Assess. Stabilize. Treat.

The purpose is to:

• Evaluate leadership health
• Identify relational and structural stress points
• Strengthen ministry alignment
• Provide stabilization strategies when needed

This process is educational, consultative, and organizational in nature.

It is not ongoing psychotherapy or medical treatment.

However, due to professional qualifications in crisis intervention, immediate stabilization support may be provided if a participant experiences acute distress during the retreat.

CONFIDENTIALITY
All assessments, disclosures, and facilitated discussions will be treated with professional discretion and ethical integrity.

Individual responses will not be publicly shared, ranked, or weaponized.

Group discussions will focus on systemic patterns rather than identifying individuals without consent.

LIMITS OF CONFIDENTIALITY
As a professionally trained Chaplain and Doctor of Christian Counseling, Dr. Green operates under ethical and legal standards as a mandated reporter.

Confidentiality must legally be broken if there is disclosure of:

Imminent danger to self
Imminent danger to others
Abuse or neglect of a minor
Abuse or neglect of a vulnerable adult
Credible threats of violence
In such circumstances, appropriate protective action will be taken in accordance with legal and ethical obligations.

Outside of these specific conditions, confidentiality will be maintained within professional boundaries.

TRAUMA-INFORMED & CRISIS-AWARE PRACTICE
This intensive is trauma-informed and crisis-aware. That means:

Participation is never forced.
Emotional safety is prioritized.
No public exposure of personal trauma.
Regulation strategies are available if activation occurs.
Immediate stabilization may be provided if acute distress emerges.
Participants are encouraged to communicate their emotional limits and request support if needed.

PARTICIPATION AGREEMENT
By signing below, I acknowledge:

I understand the purpose of this leadership intensive.
I understand the facilitator’s professional qualifications.
I understand the limits of confidentiality.
I understand this is not ongoing therapy.
I agree to participate with honesty, professionalism, and integrity.
I agree to contribute to a psychologically safe environment.

Facilitator:Dr. Jason D. Green:The Triage Room™

THE TRIAGE ROOM™
Leadership Intensive Terms & Conditions Agreement
Assess | Stabilize | Treat

1. PURPOSE OF ENGAGEMENT
This Leadership Intensive is conducted by The Triage Room™ as a structured leadership development, crisis-aware, and trauma-informed training initiative for the participating church and its leadership team.

This agreement establishes:

Confidentiality protections
Organizational integrity safeguards
Intellectual property protections
Media documentation permissions
Ethical participation standards

2. CONFIDENTIALITY & PRIVACY PROTECTION
All participants agree that:

Personal disclosures shared during assessments or facilitated discussions are confidential.
Sensitive information shared by leaders, senior leadership, or church representatives shall not be disclosed outside the retreat setting.
Discussions during this intensive are for organizational strengthening, not external dissemination.
Participants shall not:

Record private conversations without permission.
Share personal disclosures of other participants.
Use information disclosed during sessions for retaliation, gossip, or reputational harm.
The facilitator agrees:

To maintain professional discretion.
To discuss patterns and themes in aggregate form unless explicit written permission is granted.
To protect the privacy of both participants and the senior leadership.

3. PROTECTION OF SENIOR LEADERSHIP & CHURCH ENTITY
Participants acknowledge:

The purpose of assessments and dialogue is organizational health, not public exposure.
No participant shall use retreat discussions to damage the reputation of the church, its leadership, or affiliated ministries.
No internal diagnostic information may be distributed publicly without written authorization from both the church and The Triage Room™.
This clause protects both leadership and participants from reputational harm.

4. INTELLECTUAL PROPERTY & TRAINING MATERIALS
All training materials, frameworks, assessments, methodologies, language models, facilitation structures, branding elements, and documentation associated with The Triage Room™ are protected intellectual property.

This includes but is not limited to:

The Triage Model (Assess | Stabilize | Treat)
All assessment instruments
Diagnostic tools
Retreat frameworks
Slide decks and written modules
Recorded content
Customized materials created for this church
These materials may not be:

Reproduced
Distributed
Sold
Modified
Rebranded
Taught independently
Shared outside the authorized church leadership
Without prior written consent from Dr. Jason D. Green and The Triage Room™.

Unauthorized duplication or distribution constitutes intellectual property infringement.

5. AUDIO & VISUAL DOCUMENTATION CONSENT
Participants grant permission for:

Audio recording
Video recording
Photographic documentation
For the limited purposes of:

Record keeping
Internal review
Quality improvement
Training refinement
Facilitator development
Recorded material will not be publicly released, sold, or distributed without additional written consent from participants and church leadership.

If excerpts are ever requested for educational or promotional use, separate written consent will be obtained.

Participants may request not to be visually featured, and reasonable accommodation will be made.

6. NON-RETALIATION STANDARD
All participants and senior leadership agree:

No individual shall face retaliation for honest participation.
Assessments are not performance evaluations.
Data shall not be weaponized for disciplinary action.
This clause is essential for psychological safety.

7. PROFESSIONAL SCOPE & LIMITATIONS
The Triage Room™ provides leadership development, crisis intervention, and trauma-informed organizational consulting.

This engagement does not constitute:

Ongoing psychotherapy
Legal advice
Medical treatment
Mandated reporting obligations apply in cases of imminent danger, abuse, or credible threats of harm.

8. AGREEMENT & ACKNOWLEDGMENT
By checking box below, the participant acknowledges:having read in entirety ,understands and agrees to "the terms & conditions"

Understanding of confidentiality standards
Agreement to intellectual property protections
Consent to limited audio/visual documentation
Commitment to non-retaliatory participation
Understanding of professional scope and limits
Protection of Senior Leadership,Church Leadership, Participants and Church Entity

 

ENFORCEMENT & LEGAL REMEDIES CLAUSE
9. ENFORCEMENT & PROTECTION OF INTEGRITY
Due to the sensitive nature of this Leadership Intensive, including confidential disclosures, organizational diagnostics, and protected intellectual property, all parties acknowledge the seriousness of compliance with this agreement.

Any violation of the following may result in legal action:

Breach of confidentiality
Unauthorized recording or distribution of materials
Retaliation against participants for honest engagement
Misuse, duplication, or sale of The Triage Room™ intellectual property
Public dissemination of protected internal discussions
Rebranding or teaching Triage methodologies without written authorization.

The Triage Room™ reserves the right to pursue all remedies available under applicable civil law, including but not limited to:

Injunctive relief
Financial damages
Cease and desist enforcement
Legal recovery of intellectual property
Termination of engagement
Additionally, "the church entity" reserves the right to take appropriate internal action if confidentiality violations compromise organizational integrity.

This clause is not intended to create hostility, but to preserve:

Psychological safety
Ministerial integrity
Organizational trust
Legal protection for all parties involved

All participants acknowledge that the vulnerability and transparency required for this work demand mutual accountability.

Facilitator:Dr. Jason D. Green, Ed.D.

THE TRIAGE ROOM™  CONFIDENTIAL LEADERSHIP DIAGNOSTIC

Before you begin take a deep breath in through you nose and slowly out of your mouth.Relax,center and ground yourself.We are here to support the flourishing ,thriving and longevity of your Church,Ministry,Senior Leadership and most of all ...YOU. Your Emotional,Mental,Personal,Spiritual and overall health are OUR top priorities.Thank You for trusting us to serve you and your team.

Amplified Bible 3 John 1:2
Beloved, I pray that in every way you may succeed and prosper and be in good health [physically], just as [I know] your soul prospers [spiritually].

SECTION I – SPIRITUAL HEALTH TRIAGE PHASE:ASSESS

This section assesses personal spiritual vitality, identity security, and leadership from overflow rather than depletion.

Rating Scale:

1 – Rarely True (This is not characteristic of me.)
2 – Occasionally True (This shows up inconsistently.)
3 – Sometimes True (This is moderately characteristic.)
4 – Often True (This is generally consistent.)
5 – Consistently True (This is strongly characteristic of me.)

SECTION II–EMOTIONAL & MENTAL HEALTH

TRIAGE PHASE: STABILIZE

This section assesses emotional regulation, stress management, unresolved offense, and psychological sustainability in leadership.

Rating Scale:

1 – Rarely True (This is not characteristic of me.)
2 – Occasionally True (This shows up inconsistently.)
3 – Sometimes True (This is moderately characteristic.)
4 – Often True (This is generally consistent.)
5 – Consistently True (This is strongly characteristic of me.)

SECTION III – LEADERSHIP CLARITY TRIAGE PHASE: TREAT

This section assesses role clarity, decision-making confidence, delegation capacity, and alignment with organizational vision.

Rating Scale:

1 – Rarely True (This is not characteristic of me.)
2 – Occasionally True (This shows up inconsistently.)
3 – Sometimes True (This is moderately characteristic.)
4 – Often True (This is generally consistent.)
5 – Consistently True (This is strongly characteristic of me.)

SECTION IV – RELATIONAL & TEAM HEALTH

This section assesses trust levels, communication safety, accountability culture, and relational maturity within leadership.

Rating Scale:

 1 – Rarely True (This is not characteristic of me.)
2 – Occasionally True (This shows up inconsistently.)
3 – Sometimes True (This is moderately characteristic.)
4 – Often True (This is generally consistent.)
5 – Consistently True (This is strongly characteristic of me.)

SECTION V – STRUCTURE & WORKLOAD

This section assesses organizational clarity, authority lines, workload sustainability, and structural efficiency.

(If Yes/No — clarify: “This section evaluates structural clarity and operational alignment.”)

SECTION VI – BURNOUT RISK SCREEN

This section assesses emotional exhaustion, joy levels, rest patterns, and long-term sustainability in ministry leadership.

Rating Scale:

1 – Rarely True (This is not characteristic of me.)
2 – Occasionally True (This shows up inconsistently.)
3 – Sometimes True (This is moderately characteristic.)
4 – Often True (This is generally consistent.)
5 – Consistently True (This is strongly characteristic of me.)

FINAL SECTION – RETREAT EXPECTATIONS

 

Be as honest and as vulnerable as possible, this will not only assist with overall Team dynamics, but will lead to clarity in your personal support and cares needs.THIS IS TOTALLY SAFE and CONFIDENTIAL, your responses are NOT SHARED WITH ANYONE WITH THE EXCEPTION OF OUR QUALIFIED TEAM.