Walk With Me Application

All the information you share in these pages will be kept confidential. Your answers will be used only to understand if Walk With Me is a good fit for you.

This application will take about 10 minutes to complete. If you are unable to finish it today, you can save your answers and come back to the form any time during the next 30 days.

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* 1. Full Name

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* 2. Town/Area you live in

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* 3. Email

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* 4. Phone #

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* 5. Is this a cell?

Yes

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* 6. Best way to reach you

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* 7. My gender can best be described as…

Female

Non-Binary

Gender non-conforming

Agender

Transgender

Gender fluid

Bigender

Prefer not to say, but I fit the program’s mandate of self-identified female or gender diverse

My gender is not represented here. I identify as:

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* 8. I like to be referred to as… Please tell us your pronouns. Examples include she/her/hers and they/them/theirs. (This question is optional.)

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* 9. My age is

Under 19

19-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

Prefer not to answer, but I fit the program’s mandate of 19+

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* 10. I have experienced any type of abuse or violence. These experiences may have been emotional, mental, psychological, financial, spiritual, physical or sexual and happened at any point in your life. (Please know that we will never ask you to share details of your experience.)

Yes

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* 11. Please share what you have worked on—or are currently working on—in terms of your own healing (eg. programs you may have attended, a professional you received support from, or any self-healing activities): If you would prefer to tell us about this in a conversation instead, we are happy to arrange that.

Walk With Me Application

Question Title

* 1. Full Name

Question Title

* 2. Town/Area you live in

Question Title

* 3. Email

Question Title

* 4. Phone #

Question Title

* 5. Is this a cell?

Question Title

* 6. Best way to reach you

Question Title

* 7. My gender can best be described as…

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* 8. I like to be referred to as… Please tell us your pronouns. Examples include she/her/hers and they/them/theirs. (This question is optional.)

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* 9. My age is

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* 10. I have experienced any type of abuse or violence. These experiences may have been emotional, mental, psychological, financial, spiritual, physical or sexual and happened at any point in your life. (Please know that we will never ask you to share details of your experience.)

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* 12. Why do you want to participate in the Walk With Me program? What do you hope to achieve?

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* 13. Three words my friends would use to describe me are…

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* 14. How did you hear about Walk With Me?