Stepping Stone to a New Life

Date:

Date

First Name:

Last Name:

Phone Number:

Street Address:

City:

State:

Postal /Zip Code:

Email:*

example@example.com

Date of Birth:

Date

Current living arrangement: (e.g., renting, staying with friends, own home, etc.)

Do you have children - If yes, name/age:

Work/Employment Background:

Employer/Self Employed (business name):

If not currently working: Do you have goals for employment or business?

Do you have a mentor/coach or programs you're signed up for?

Do you have a resume? If yes, forward to contact@safepassageheals.org

How did you find out about Safe Passage?

What was your childhood like?

History of abuse, drugs, alcohol or mental abuse:

Have you ever received counseling? How long? What kind?

Do you feel it helped you? In what way?

Have you ever been arrested? If yes, explain:

Do you have a disability? If yes, explain:

Are you currently taking any medication or drugs? If yes, explain:

What goals would you like to achieve:

If we feel that you need other help that we are not equipped to provide for you, would you be willing to be referred to another organization?

Have you been diagnosed with any Mental Illness?

Can you visualize being successful and giving back?

What services would you be interested in?

Health & FitnessCounselingSpiritual Guidance

This is a program, which is designed to equip women and their children (who have been victims of abuse or domestic violence), to become productive members of our society, willing to give back and help other women and their children, who are in the same situation. Stepping Stones to a New Life is a program which takes commitment, determination and willingness to change. With your new confidence and the support of the Safe Passage Heals Team of Experts, you will be able to move forward with a new and successful life. Initial Here*

We have a team of experts that bring their talents and expertise to help restore and transform your self-esteem by giving you the tools you will need to overcome the scars of domestic violence and/or mental abuse. You will learn to let go of the past and be willing to embrace the program so that the cycle of domestic violence will be broken. You understand and accept that during the program you must stay free from any serious relationships so that the cycle of domestic violence and abuse can be broken and the healing process may be fully established. Initial Here*

Clients that have children must arrange for childcare on the days that children will not be allowed to attend the workshops. We will be able to reimburse you for the childcare, in the case that you are not working. Safe Passage will help with your transportation and or bus fares. All children will go through an interview process and will be assigned to a mentor. We feel that every family member is affected by domestic abuse in one way or another and that the cycle needs to be broken with each and every member of the family. Initial Here*

This program asks each woman to give a 6-month commitment to attending the counseling sessions and workshops that are provided by Safe Passage Heals and their team of professionals. After 6 months of transformation, we ask every woman to participate with us for 6 more months to volunteer and give their testimony on how the Safe Passage Heals team transformed their life. This may be done at our charity events, on video, newsletter or at our company meetings. You must be able to volunteer at our office twice a month or at one of our events before or after your graduation. Initial Here*

Counseling starts immediately and is a once a week commitment. There may also be a workshop that same week and they are both important. If you miss 2 appointments without a 24-hour notice you will be dropped from the program. Some women may qualify for dental work and some may qualify for corrective surgery. If you qualify to receive either service it is very
important that when going to the Doctor/ Dentist office you arrive on time. It is your responsibility to arrange for someone to take you to your appointments and take care of you while recovering from surgery. All services by any of the Doctors or Dentists who are part of our program terminate 100% once you have finished the programInitial Here*

If you decide to leave our program for any reason or we feel you are not participating in the program you will be terminated. You will no longer be able to participate in our program and all services stop immediately.
You understand that treatment of any kind is only available to you while active in our program. You also understand that after completing the program or if you should drop out of it or be terminated for any reason, you are not to contact any of the Doctors, Dentists and or people that you have been seeing while part of our program. Signature*

THE PROGRAM

1. Up to 12 Weeks of Counseling

2. Vision Board Workshop (Required to Remain Active In Program)

3. Goal Setting Workshop (Required to Remain Active In Program)

4. Health Assessment & Nutrition Education Workshop (Required to Remain Active In Program)

5. Beauty from the Inside-Out - Building Confidence & Make-overs Workshop (Required to Remain Active In Program)

6. Resume Writing & Interview Skills (Outside Resource)

7. Grief Support

8. Self-Defense Classes & Fitness for the whole family

9. Dress for Success "How to Be an Elegant Successful Woman." & Improving Public Speaking Skills. Free Business attire, shoes and other personal products.

10. Give funds for transportation or bus passes for appointments

11. Help with finding new housing, and supplies for furniture and household items.

12. Access to business attire, shoes, and other personal products

13. Parenting Skills & Mentorship for Children

14. Runway of Hope Event

It is the Policy of Safe Passage Heals, that the clients do not contact any of our donors, supporters, exercise coaches, doctors, dentists or anyone giving services to you through Safe Passage Heals without the direction of the Program Director, while in the program or after leaving.

ARBITRATION OF DISPUTES OR LAWSUITS BETWEEN CLIENT AND SAFE PASSAGE: If you decide to start a dispute or a lawsuit against Safe Passage Heals, You agree to pay ALL fees and costs associated with this arbitration or lawsuit.

I First Name* Last Name* give Safe Passage Heals permission to take my photo for the purpose of the clients profile.

I have read and understand the program and I understand the commitment I am making to myself and to Safe Passage Heals.

By signing this agreement, I acknowledge that I have thoroughly read the foregoing and fully understand and agree to each and all of the terms and conditions set forth herein.
Signature* Date*