We are so glad you've taken this brave step in healing!

What you're signing up for: Our 1:1 Mentor program is an 8 week journey involving walking you through 7 essential steps in healing covered in Crystal Sutherland's book, Journey to Heal: Seven Essential Steps of Recovery for Survivors of Childhood Sexual Abuse. This is not counseling, but rather a program that pairs you with another survivor who has been through this 8 week study and has experience in leading other women through the same.

Materials you will need: A copy of Crystal's book: Journey to Heal, a personal journal, and a copy of The Bible in a translation you can easily understand/read.

Completing this form: Registration is free, but required to participate. In order to better understand your needs and connect you with the right mentor, please complete our form with as much information as you can share.

Once we receive your request, we'll review and proceed to connect you with one of our mentors. They will contact you directly, either by phone or email, based on the contact information you provide.

Please note: our mentors are not licensed therapists, psychiatrists or psychologists, but survivors who have experienced healing, learned how to thrive in Christ, and desire to help others do the same.

Confidentiality Note: All information contained in this form is confidential and is used for the sole purpose of the group. 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.

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* 1. Full Name:

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* 2. Age or Birthdate:

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* 3. Email:

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* 4. Best Contact Phone #:

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* 5. City & State:

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* 6. How did you hear about the Journey to Heal Study?

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* 7. What made you to decide to sign up for the study at this time?

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* 8. Your abuse/assault was committed by:

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* 9. Your age(s) during the abuse/assault:

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* 10. Time frame of abuse/assault:

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* 11. What steps have been taken, if any, to begin the healing process? (Example: Counseling, support group, doctor, reported to authorities/filed charges, talked to a friend, haven't told anyone.)

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* 12. Are you currently seeing a counselor/therapist?

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* 13. Do you suffer from any specific mental or physical health concerns? (i.e. Bipolar Disorder, Borderline Personality, pelvic or back issues, chronic migraines, chronic lower back pain)

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* 14. Have you struggled with suicidal thoughts or attempted suicide within the past two years?

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* 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?

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* 16. Are you on any kind of medications for anxiety, depression, or any health condition related to your mental health?

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* 17. Are you struggling with any kind of addictions? (Particularly substances, alcohol, or sex)

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* 18. Are you in any form of contact with the person(s) who abused you?

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* 19. Are you currently being abused in any way? If so, please explain:

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* 20. Do you understand that this is a Gospel-centered, Biblically based women's study for survivors of sexual abuse?

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* 21. Describe your relationship with Jesus Christ:

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* 22. Are you currently attending a local church or women's Bible study?

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* 23. What do you hope to gain from taking this study?

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* 24. What is the name and number of who you'd like us to contact in case of an emergency?

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* 25. Additional Comments:

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