Support group interest form

Hello! We are so happy you are interested in participating in our support group. Please take a few minutes to complete the form and we will connect with you very soon!

Groups typically last between 1 - 2 hours

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* 1. What is your first and last name?

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* 2. What is your date of birth?

Date / Time

Date

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* 3. What is your phone number?

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* 4. What is your email?

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* 5. Are you interested in meeting Virtually or In - Person?

Virtual *times may vary*

In-Person

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* 6. What topics are you interested in discussing in the support group?

If you've been harmed in your intimate and/or domestic relationships

Learning about victim rights (court process, police reports, etc.)

Learning about healthy relationships

Exploring trauma and it's affects on the mind and body

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* 7. What days are most convenient for you?

Monday

Tuesday

Wednesday

Thursday

Friday

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* 8. What times are most convenient for you?

9am - 11am

11 am - 1pm

1pm - 3pm

3pm -5pm *Only on Tuesdays and Thursdays

If virtual please relay times that are convenient for you when contacted