Kintsugi Project Interest Form

Brown Girl Wellness

Brown Girl Wellness, Inc. proudly presents the Kintsugi Project, a month-long virtual wellness journey designed to empower women of color who have experienced trauma to reclaim their lives.

Question Title

1. Who are you? Why would you like to join the Empowerment Project? (Required.)

Question Title

2. How would you rate your current level of stress? (Required.)

A great deal

A lot

A moderate amount

A little

None at all

Question Title

3. Which of the following themes are you most interested in exploring? Select all that apply. (Required.)

Grief

Forgiveness

Empowerment

Renewal

Self-love

Question Title

4. Are you a single mother or grandmother with children in the home? (Required.)

Yes, I am a single mother

Yes, I am a grandmother

Question Title

5. What’s going on in your life? What are the current stressors in your life? (Required.)

Question Title

6. Are you available to participate virtually? What day/time works best? Are you available for one Saturday (in-person) during the month in your community? (Required.)

Yes

Maybe

Kintsugi Project Interest Form

Brown Girl Wellness

Question Title

1. Who are you? Why would you like to join the Empowerment Project? (Required.)

Question Title

2. How would you rate your current level of stress? (Required.)

Question Title

3. Which of the following themes are you most interested in exploring? Select all that apply. (Required.)

Question Title

4. Are you a single mother or grandmother with children in the home? (Required.)

Question Title

5. What’s going on in your life? What are the current stressors in your life? (Required.)

Question Title

6. Are you available to participate virtually? What day/time works best? Are you available for one Saturday (in-person) during the month in your community? (Required.)

Question Title

7. What do you hope to gain from participating in the Empowerment Project? (Required.)

Question Title

8. Have you participated in a wellness programs before? (Required.)

Question Title

9. Please provide your name (Required.)

Question Title

10. Please provide your email address (Required.)

Kintsugi Project Interest Form

Brown Girl Wellness

Question Title

* 1. Who are you? Why would you like to join the Empowerment Project? (Required.)

Question Title

* 2. How would you rate your current level of stress? (Required.)

Question Title

* 3. Which of the following themes are you most interested in exploring? Select all that apply. (Required.)

Question Title

* 4. Are you a single mother or grandmother with children in the home? (Required.)

Question Title

* 5. What’s going on in your life? What are the current stressors in your life? (Required.)

Question Title

* 6. Are you available to participate virtually? What day/time works best? Are you available for one Saturday (in-person) during the month in your community? (Required.)

Question Title

* 7. What do you hope to gain from participating in the Empowerment Project? (Required.)

Question Title

* 8. Have you participated in a wellness programs before? (Required.)

Question Title

* 9. Please provide your name (Required.)

Question Title

* 10. Please provide your email address (Required.)

1. Who are you? Why would you like to join the Empowerment Project? (Required.)

2. How would you rate your current level of stress? (Required.)

3. Which of the following themes are you most interested in exploring? Select all that apply. (Required.)

4. Are you a single mother or grandmother with children in the home? (Required.)

5. What’s going on in your life? What are the current stressors in your life? (Required.)

6. Are you available to participate virtually? What day/time works best? Are you available for one Saturday (in-person) during the month in your community? (Required.)

7. What do you hope to gain from participating in the Empowerment Project? (Required.)

8. Have you participated in a wellness programs before? (Required.)

9. Please provide your name (Required.)

10. Please provide your email address (Required.)