On behalf of the YWCA San Gabriel Valley, thank you for your interest in the Emotional Wellbeing Sessions for those impacted by the Southern California Wildfires. Please complete the interest form, and you will be contacted for next steps in the participation process.

Informed Consent:
By completing this interest form, you give your informed consent for YWCA San Gabriel Valley to contact you for your interest in the Emotional Wellbeing Sessions.

Interest forms will be archived for data tracking purposes on fire relief efforts and best practices - but your personal information will not be shared with any outside parties.

For Questions or Concerns, please contact:
Christina Capul, MPH
P). (626) 533-9144
E). christinacapul@ywcasgv.org

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1. First Name: (Required.)

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2. Last Name: (Required.)

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3. Phone Number: (Required.)

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4. Email Address: (Required.)

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5. What would you like to receive from the Emotional Wellbeing Sessions:
 (Required.)

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6. Which Emotional Wellbeing Session would you prefer to attend:
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7. What is the best time for a 15-minute follow-up phone call:
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