Affirming Hearts Academy: Healthy LGBTQ+ Relationships Group
Interest Form

This interest survey is for our cohort beginning in June 2025. Thank you for your interest in Affirming Hearts Academy, Mazzoni Center's healthy relationships educational group for LGBTQ+ folks! Please fill out the survey below and we will be in contact soon.

This project was supported by 15JOVW-22-GG-00404-UNDE awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this document are those of the author and do not necessarily reflect the views of the U.S. Department of Justice, Office on Violence Against Women.

Question Title

* 1. Please enter your contact information so we can reach out to you. We primarily communicate via Email.
We will not share this information.

Name you go by (first and last) *

Pronouns *

Email Address

Confirm Email Address *

Phone Number (please use the following format: xxx-xxx-xxxx)

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* 2. Do you identify as LGBTQ+?
This group is for folks that identify as LGBTQ+ or an identity under the LGBTQ+ umbrella

Yes

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* 3. Are you based in Philadelphia or the surrounding area?
This group meets in person in Philadelphia

Yes

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* 4. Where did you hear about this group?

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* 5. Why are you interested in learning about healthy LGBTQ+ affirming relationships?

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* 6. What age range are you in?
We do not offer healthy relationships groups for folks 13 or younger at this time.

*If you are 18 and in high school, please choose the first option. If you are 18 and out of high school, please choose the second option.

14-18

18-25

26-35

36-45

46-55

56-65

66+

Affirming Hearts Academy: Healthy LGBTQ+ Relationships GroupInterest Form

Question Title

* 1. Please enter your contact information so we can reach out to you. We primarily communicate via Email. We will not share this information.

Question Title

* 2. Do you identify as LGBTQ+?**This group is for folks that identify as LGBTQ+ or an identity under the LGBTQ+ umbrella**

Question Title

* 3. Are you based in Philadelphia or the surrounding area?**This group meets in person in Philadelphia**

Question Title

* 4. Where did you hear about this group?

Question Title

* 5. Why are you interested in learning about healthy LGBTQ+ affirming relationships?

Question Title

* 6. What age range are you in?We do not offer healthy relationships groups for folks 13 or younger at this time.*If you are 18 and in high school, please choose the first option. If you are 18 and out of high school, please choose the second option.

Affirming Hearts Academy: Healthy LGBTQ+ Relationships Group
Interest Form

* 1. Please enter your contact information so we can reach out to you. We primarily communicate via Email.
We will not share this information.

* 2. Do you identify as LGBTQ+?
This group is for folks that identify as LGBTQ+ or an identity under the LGBTQ+ umbrella

* 3. Are you based in Philadelphia or the surrounding area?
This group meets in person in Philadelphia

* 6. What age range are you in?
We do not offer healthy relationships groups for folks 13 or younger at this time.

*If you are 18 and in high school, please choose the first option. If you are 18 and out of high school, please choose the second option.