Spunk! Registration

Spunk! Registration

Hi there, thanks for your interest in the Spunk! program, a support group at ACT for guys into guys interested in making a change around their substance use. Please answer this brief questionnaire and we will be happy to connect you with more information about this program. All answers that you share will be kept strictly confidential.

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* 1. What is your name?

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* 2. Briefly describe the reason(s) why you are interested in Spunk! or describe what you hope to gain from participating in the group. (1-3 sentences)

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* 3. This program is for gay, bi, or queer men. Do you identify with any of these identities or as a guy into other guys?

Yes

No

Not listed (please specify)

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* 4. This program is specifically for men. Do you identify as either a man, trans man, 2-spirit, or a non-binary person?

Yes

No

Not listed (please specify)

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* 5. Is it alright if we contact you for more information about this program?

Yes

No

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* 6. What is your e-mail?

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* 7. What is your phone number?

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* 8. How do you prefer to be contacted? (check all that apply)

Phone

E-mail