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1:1 JTH Mentor Request Form

Journey to Heal 1:1 Program Request

The JTH 1:1 Mentor Program is a peer recovery program involving an 8-week journey through the book, Journey to Heal: Seven Essential Steps of Recovery for Survivors of Childhood Sexual Abuse by Crystal Sutherland. Through this registration process we will endeavor to pair you with a member of our volunteer Mentor Team who will be your guide through our 8-week program.

How Registration Works:

Completing this registration form is your first step in our registration process. Please answer the following questions with authenticity and care. Once completed you'll recieve an email from our program coordinator to set up a time to meet with her briefly by phone or via Zoom . This meeting allows our team to review your form and answer any questions you might have about the program. If our program is the right fit for you, we'll then connect you with one of our volunteer Mentors. They will contact you directly, either by phone or email, based on the contact information you've provided here.

Please note, our mentors are not licensed therapists, psychiatrists or psychologists. They are women who are survivors who have experienced hope and healing through the Journey to Heal study and desire to help others do the same.

We look forward to walking with you as you continue your healing journey.

Blessings,

The Journey to Heal Mentor Team





Confidentiality Note: All information contained in this form is confidential. We understand these questions are sensitive and appreciate your willingness to help us better understand your story and create a safe place for you to heal.
1.Your Full Name:(Required.)
2.Age or Birthdate:(Required.)
3.Your Best Contact Email:(Required.)
4.Your Best Contact Phone #:(Required.)
5.City & State:(Required.)
6.How did you hear about the Journey to Heal Study?(Required.)
7.What made you to decide to sign up for the study at this time?(Required.)
8.Your abuse/assault was committed by:(Required.)
9.Your age range during the abuse or assault?(Required.)
10.Time frame of abuse/assault:(Required.)
11.What steps have you taken, if any, to begin the healing process? (Example: Counseling, support group, medical, reported to authorities/filed charges, talked to a friend, haven't told anyone.)(Required.)
12.Are you currently seeing a counselor/therapist?(Required.)
13.Do you suffer from any specific mental or physical health concerns? (i.e. PTSD, Bipolar Disorder, Borderline Personality, pelvic or back issues, chronic migraines, IBS, or panic attacks?)(Required.)
14.Have you struggled with suicidal thoughts or attempted suicide within the past two years?(Required.)
15.Do you struggle with anxiety, depression, physical pain, intimacy/relationship issues, self-harming, eating disorders, anger, flashbacks, or other PTSD symptoms? And/or have you been diagnosed with PTSD (Post Traumatic Stress Disorder)? If so, when?(Required.)
16.Are you on any kind of medications for anxiety, depression, or any health condition related to your mental health?(Required.)
17.Are you struggling with any kind of addictions? (Particularly substances, alcohol, porn or sex)(Required.)
18.Are you in any form of contact with the person(s) who abused you?(Required.)
19.Are you currently being abused in any way? If so, please explain:(Required.)
20.Do you understand that this is a Gospel-centered, Biblically based women's study for survivors of sexual abuse?(Required.)
21.Briefly describe your relationship with Jesus Christ, and what (if any) faith practices you currently employ:(Required.)
22.Are you currently attending a local church or women's Bible study?(Required.)
23.What do you hope to gain from taking the Journey to Heal Study?(Required.)
24.What is the name and number of who you'd like us to contact in case of an emergency?(Required.)
25.Additional Comments:(Required.)