Expression of Interest to attend Circles of Support programs

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1. What is your name? (Required.)

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2. Contact phone number (Required.)

Phone Number

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3. Contact email address (optional)

Email Address

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4. Which future Circles of Support programs are you interested to attend? (Tick all that apply) (Required.)

Darwin

Palmerston

Alice Springs

Katherine

Online program

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5. Why are you interested in the Circles of Support program? (Tick all that apply) (Required.)

To meet other people with a loved one who experiences issues related to mental health, alcohol or drug use

To learn about mental health, alcohol and drug related misuse and co-occurring issues

To understand recovery and ways to support recovery

To learn ways to support your own wellbeing and practice self-care

To manage overwhelming emotions and responses

To learn how to identify and respond during a crisis

To learn how to respond to sigma and discrimination

To learn ways to effectively communicate your needs and rights

To learn how to set boundaries

To access support for myself

To understand how to navigate the mental health and alcohol and other drug service system

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6. Please confirm the following background information: (Tick all that apply) (Required.)

I am over 18 years of age

I have a loved one who experiences an alcohol or other drug and/or mental health problem

At this point in time, I can commit to attending most/all of the sessions I have indicated

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7. Please confirm that you are the person named in this Expression of Interest form, or that they have provided you with consent to fill the form in on their behalf: (Required.)

I agree

Expression of Interest to attend Circles of Support programs

Question Title

* 1. What is your name? (Required.)

Question Title

* 2. Contact phone number (Required.)

Question Title

* 3. Contact email address (optional)

Question Title

* 4. Which future Circles of Support programs are you interested to attend? (Tick all that apply) (Required.)

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* 5. Why are you interested in the Circles of Support program? (Tick all that apply) (Required.)

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* 6. Please confirm the following background information: (Tick all that apply) (Required.)

Question Title

* 7. Please confirm that you are the person named in this Expression of Interest form, or that they have provided you with consent to fill the form in on their behalf: (Required.)

1. What is your name? (Required.)

2. Contact phone number (Required.)

3. Contact email address (optional)

4. Which future Circles of Support programs are you interested to attend? (Tick all that apply) (Required.)

5. Why are you interested in the Circles of Support program? (Tick all that apply) (Required.)

6. Please confirm the following background information: (Tick all that apply) (Required.)

7. Please confirm that you are the person named in this Expression of Interest form, or that they have provided you with consent to fill the form in on their behalf: (Required.)