Queering Spirituality
Interest Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Pronouns
How did you hear about this group?
What is bringing you to this group?
What are your goals?
Do you have experience with support groups?
Yes
No
Please describe further.
Do you have established care for one-on-one counseling?
Yes
No
Are you open to this kind of care should we assess that it is helpful?
Yes
No
Can you commit to six sessions on Thursdays from 7:30-8:30pm?
Yes
No
If this time does not work, would you be interested in being contacted in the future about support group opportunities?
Yes
No
Do you have an established faith based or spiritual practice?
Yes
No
Please describe further.
Do you have any questions or concerns about joining this support group?
Yes
No
Please let us know what they are.
The next step is to schedule a phone call with one of the facilitators. One of them will reach out to schedule 15 minutes to talk with you within the next two days.
Submit
Should be Empty: