The Bravery After Betrayal: It Takes Fierce Strength Retreat Agreement
Participant Liability Release Form
Please review and fill out the form.
Welcome to the Bravery After Betrayal: It Takes Fierce Strength Retreat! We can't wait to connect with you in person. Please review the following information carefully. We want you to be familiar with policies/procedures so that things can run smoothly. Please read this very carefully so that there are no misunderstandings later on. If you have any questions please email the BraveOne Team at email@example.com. We’ll be happy to assist you.
The BraveOne Team
The Bravery After Betrayal: It Takes Fierce Strength Retreat, hereinafter known as the “Retreat” is a valuable, private, and confidential Retreat. I agree to treat my time there with the upmost respect and care. I understand that Retreat attendees’ names and any comments or discussions that occur during the Retreat are strictly confidential. By typing my name below, I agree to maintain confidentially of all attendees of the Retreat.
I understand that the staff and Coaches of the Retreat may be considered mandated reporters; thus, required to report to the proper authorities any of the following:
- Any reasonable suspicion of physical or sexual abuse of a child, minor, elder, or an adult with a disability.
- When a participant communicates a threat of bodily injury to others.
- When a participant may be a threat to herself or has plans of suicide.
I understand that I am responsible for the decisions I make about my time at the Retreat. The Retreat staff and Coaches are happy to share opinions, offer resources, or make referrals. However, it is up to me to decide which, if any, to act upon.
I understand that if I decide to take a recommendation the Retreat staff and Coaches give, it is my choice and I take full responsibility for it. If I decide to work with someone based on a referral, I understand that the workings of that relationship will be entirely separate from my relationship with the BraveOne Community, the Retreat, its staff, and Coaches.
I understand that I may stop attending the Retreat at any time. If I choose to do so, I understand that my fees will not be refunded.
At the end of the Retreat, I understand that I will be asked to write a few comments about my time at the Retreat as an evaluation. I understand that it helps the Retreat staff to see what I liked about the process, what results I received overall, and anything else I would like to add. I understand that the Retreat staff and Coaches may use my comments in the form of a client testimonial to share with others who are thinking of attending the Retreat. I understand that it is my responsibility to let the Retreat staff and Coaches know if I do NOT want my evaluation or comments used from the closing evaluation. This DOES NOT include any and all comments made during the Retreat. Those will ALWAYS remain confidential and will never be shared by the Retreat staff and Coaches.
I understand that the Retreat staff and Coaches want me to be satisfied with my Retreat experience. I agree that if the Retreat staff or Coaches ever say or do something that upsets me or doesn’t feel right, I will bring it up either to a Retreat staff or Coach. All comments can be emailed to firstname.lastname@example.org if there are any after the Retreat is over.
I understand that the Retreat is open to all participants regardless of their faith orientation. Some elements of the teaching draw from references to God and from a Christian-based philosophy, which may influence the teaching/group support and/or coaching I receive at the Retreat.
I understand that participants at the Retreat come from all ranges of trauma experiences, varied beliefs, lifestyles, orientations, socioeconomic, age, and spiritual faith experiences. Healing comes as we curiously enter into understanding a person’s experience from a non-judgmental stance. It is requested that we refrain from trying to fix another person or impose beliefs that we deem may be best for that individual. The devastation that comes by way of existential trauma, relational trauma, socioeconomic trauma, spiritual/faith trauma has the ability to be processed and worked through at the Retreat.
I understand that I am responsible for my own results in connection at the Retreat. I understand that if I choose not to implement things I’ve learned at the Retreat, I may not see the progress I’m hoping for.
If I have been advised by my physician or psychiatrist to use medication of any kind, I agree to continue using my medications as prescribed during the course of the Retreat.
I further understand and acknowledge that the Retreat is not psychiatric treatment, and that no doctor-patient or therapist-client relationship is established by my participation in this Retreat.
I agree to cooperate fully with the staff and Coaches of the Retreat, and I understand that failure to do so may result in removal from the Retreat.
RELEASE OF INFORMATION:
I authorize the Retreat staff, its coaches, supervisors, and BraveOne Team to release and disclose information to other Retreat staff, coaches, supervisors, and BraveOne Team members at the Retreat for the purpose of coordinating care.
NO MEDICAL ADVICE, MENTAL HEALTH COUNSELING, OR INSURANCE REIMBURSEMENT:
The Retreat staff and Coaches are not intended to provide mental health treatment, and does not constitute a client/therapist relationship. I understand that the Retreat and the BraveOne Community Inc., nor its employees, members, representatives, coaches, and agents do not provide diagnosis. I understand that the Retreat does not provide any type of superbill or receipt for coaching services. The Retreat does not work with insurance companies and does not provide any type of paperwork for insurance reimbursement and as a result of this I understand that I may not be reimbursed by my insurance company and agree to take on the responsibility of payment for services rendered regardless.
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but the virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life-threatening illness and even death. BraveOne Community Inc. cannot prevent you or your family members from becoming exposed to, contracting, or spreading COVID-19 while utilizing BraveOne Community Inc. services or at the Retreat premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to utilize BraveOne Community Inc. services or attend the Retreat you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19.
I choose to accept the risk of contracting COVID-19 for myself and/or my family in order to utilize The BraveOne Community Inc.’s services and attend the Retreat. Additionally, I will take responsibility for my health and how I manage my own personal concerns while at the Retreat. These services are of such value to me that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to utilize BraveOne Community Inc.’s services and premises in person.
I hereby forever release and waive my right to bring suit against BraveOne Community Inc., their officers, directors, employees, agents and subcontractors, Dr. Sheri Keffer, Kyle Keffer, Karene Dodson/Integral Solutions, all Retreat staff and Coaches, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to utilizing BraveOne Community Inc’s services and attending the Retreat. I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.
COPYRIGHT OF MATERIALS:
I understand that materials provided to me during the Retreat are copyrighted. Under no circumstances can the copy in these documents be used or reproduced in whole or part without the express written permission of BraveOne Community Inc and Dr. Sheri Keffer. The absence of a copyright notice on any given page or material should NOT be construed as an absence of copyright. These copyrights have been successfully defended in the past, and it is the policy of BraveOne Community Inc to aggressively defend all intellectual properties.
RELEASE OF LIABILITY:
By typing my name below, I agree that I am a voluntary participant at the Retreat. I agree to release and discharge as well as agree to indemnify and hold harmless Dr. Sheri Keffer, Kyle Keffer, BraveOne Community Inc, Karene Dodson/Integral Solutions, all Retreat staff and Coaches, their officers, directors, employees, agents and subcontractors, against all actions, causes of actions, health issues, sicknesses, claims, demands, costs and expenses and liabilities of any nature whatsoever that I may suffer directly or indirectly during the course of or as a result of my participation at the Retreat.
I have read and agree to the policies and procedures above. A copy of this document will be emailed to me at the address provided.
Copyright © 2022 Dr. Sheri Keffer. All Rights Reserved.