Healing Connections Peer Support Group Registration Request

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* 1. Please enter your contact information.

Name

City/Town *

State/Province *

Email Address *

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* 2. Please select your pronouns:

She/Her/Hers

He/Him/His

They/Them/Their

Other (please specify)

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* 3. I confirm I received, read, and agree to the Healing Connections Peer Support Group Agreement. I understand my registration request is pending.

Yes, I confirm.

No, please resend the Healing Connections Peer Support Group Agreement.