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| We are a non profit organization. We would appreciate a donation. Please send a check, money order, or use Pay Pal. I understand that by signing this release form that: - GIFT FROM WITHIN will assist me in finding a phone/pen/email support pal. - GIFT FROM WITHIN will create a short biography based on my completed form that will be shared with members only. - GIFT FROM WITHIN will keep my name and address confidential within the support pal network. - GIFT FROM WITHIN will send me names and addresses after I return the questionnaire and complete a telephone screening with Joyce Boaz. - GIFT FROM WITHIN may from time to time send me questionnaires that will be computerized and only used for scientific studies on PTSD. I hereby authorize the use of such questionnaires that I may sign for such purposes. As a GFW Phone-Pen-Email Support Pal, I agree to the following: 1. All names will be kept confidential; 2. That I will not hold GFW or its Board Members responsible or liable in the event that the relationship does not work, no matter the reason. I understand there are no guarantees and some risk is involved. 3. I understand that a support pal could say something during our correspondence or communications that could be triggering and I need to be mindful of my own needs and limitations. I will also behave kindly and gentle towards others, remembering we are all in this together. Please provide: Personal History: name, age, gender, traumatic experience, why you want this service. (Some of this info will be shared with members only). Please print: Date_________________________________ Name____________________________________________________ Address_______________________________________________________________ City___________________________________ State________ Zip________________Country__________________ Why I want this service (include traumatic event) Occupation__________________________________________________________________ Hobbies and/or things that I enjoy___________________________________________ How did you find us?_________________________________________________________ Language Preferences (bilingual helpful)__________________________________ Phone______________________________________________ Email: ________________________ Best time to reach you_____________________________________________________ Your signature___________________________________________________________ Witness________________________________________________________________ |
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