Registration Form Youth Support Group (14-17)

Group Description & Scope of Services

This group is a faith-based peer support group for girls ages 14-17 who have experienced any form of sexual violence. The purpose of the group is to provide emotional support, encouragement, spiritual support, psychoeducation, and healthy community connection in a safe and respectful virtual environment.

This group is NOT psychotherapy, clinical counseling, mental health treatment, crisis intervention, or a substitute for

professional therapy services.

Facilitators may have professional backgrounds; however, participation in this group does not establish a therapist-client relationship.

Participants may be referred to outside mental health resources or crisis services if facilitators believe additional support is needed.

Faith-based Nature of Group

This group incorporates faith-based themes, values, prayer, encouragement, and optional spiritual discussion. Participants are welcome regardless of where they are in their faith journey.

No participant will be pressured into sharing spiritual beliefs or participating in prayer.

Participant Information

Parent/Guardian Information

Emergency Contact Information

Medical and Safety Information

Please share any information that may help facilitators support your safety during group participation.

Crisis and Emergency Disclaimer

This group is not equipped to provide emergency mental health services or crisis intervention.

If a participant experiences:

• suicidal thoughts

• self-harm behaviors

• severe emotional distress

• active abuse or unsafe living conditions

Facilitators may contact the parent/guardian, emergency contacts, crisis resources, or appropriate authorities as needed for safety.

If immediate emergency assistance is needed, call 911 or go to the nearest emergency room.

National Sexual Assault Hotline: 800-656-4673

988 Suicide & Crisis Lifeline: Call or Text 988

Group Participation Expectations

Participants agree to:

• Treat others with kindness and respect

• Avoid bullying, harassment, or intimidation

• Respect personal boundaries

• Refrain from sharing other participants’ stories outside the group

• Use appropriate language and behavior

• Participate in ways that support emotional and physical safety for everyone

Facilitators reserve the right to remove a participant from the group if behavior or communication creates safety concerns or significantly

disrupts the group environment.

Confidentiality & Limits of Confidentiality

Facilitators encourage all participants to respect one another’s privacy and keep personal stories shared within the group confidential. However, confidentiality in a group setting cannot be guaranteed.

Participants and families understand that facilitators may be legally required to disclose information if:

• A participant reports abuse or neglect

• There is suspected abuse of a minor

• A participant expresses intent to harm themselves or others

• There is concern regarding participant safety

• Disclosure is otherwise required by law

Participant Agreement

By signing and submitting this form I confirm that I have fully read, acknowledge and understand that:

• This is a faith-based support group and not formal therapy

• Participation is voluntary and I can withdraw at anytime

• Sensitive topics related to trauma and sexual violence may arise

• Confidentiality in a group setting cannot be guaranteed

• Facilitators are mandated reporters under Missouri law. Facilitators are required to honor the Missouri statute, no matter where a participant is located.

• Facilitators may recommend outside counseling or higher levels of support when appropriate

• This group is meant to be respectful and supportive

• Everyone’s stories deserve privacy and respect

• I can choose what I do or do not share

• I should speak to a facilitator if I feel unsafe or overwhelmed