Support Group Request Form

Support Group Request Form

Bellis offers expert-led, peer-based emotional support. Please answer a few questions so our team can point you in the right direction. We are committed to serving as a uniquely compassionate source of support. All information is confidential and will never be shared. We'll respond ASAP, but please know responses are not monitored 24 hours a day.
If you need a listening ear before our next meeting, the Stronger Together Support Line is available for you. Feel free to call or text anytime at 833-4BELLIS (833-423-5547) - a trained team member will be ready to pick up the call or respond promptly.
Please select the description below that best describes your experience. (Feel free to pick more than one.)

You made an adoption plan for your child (to be parented by someone else) as an intentional, self-directed choiceYour parental rights were terminated by the courts after involvement by child protection services (whether voluntary or involuntary, you had little or no choice)You made an adoption plan for your child (to be parented by someone else) after involvement by child protection servicesYou transferred custody to another caretaker for your children after involvement by child protection servicesYou adopted a child (international, domestic, kinship, or foster care)You grew up as an adopted person (international, domestic, kinship, or foster care)You supported a close family member or friend through an adoption process, including open or closed adoptions with grandchildren and othersOther
Is there anything you want us to know about your situation and the support you need?
In what year(s) did your placement or termination take place?
If you attend virtual meetings, can you participate in a private setting, where no one else can hear the meeting?
If you are a social service professional seeking support for a client, please provide any helpful information so we can assist you.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you agree to opt-in to receive text messages about upcoming support meetings? You may opt-out at any time by replying "STOP."

I agree to opt-inI do not agree to opt-in
E-mail*
example@example.com
How did you learn about Bellis?
General Information Form

Thank you for your willingness to complete the following general information questions. You can choose to not answer questions you do not want to answer and/or stop at any time. We will protect all information by keeping all forms anonymous and safely storing the responses. If you have questions, please contact Vanessa@mybellis.org.
What is your current age?
Which of the following best describes your race or ethnicity?

American Indian or Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhite
What is the highest level of schooling you completed?

Less than high schoolHigh school graduate (diploma or GED)Some collegeAssociate's degreeBachelor's degreeMaster's, professional, or doctoral degree
What is your current marital status?

SingleMarried or partnered
Are you currently pregnant?

YesNoNot sure
Adverse Childhood Experiences (ACEs)

The next set of questions are about events that happened during your childhood, defined as the first 18 years of your life. Your responses to all of these questions are confidential and will help Bellis gain a better understanding of challenges you may have faced earlier in life and provide context for your experiences as an adult.
While you were growing up, during the first 18 years of life:
Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?

YesNo
Did a parent or other adult in the household often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?

YesNo
Did an adult or person who was at least 5 years older than you ever: touch or fondle you or have you touch their body in a sexual way? Or attempt to actually have oral, anal, or vaginal intercourse with you?

YesNo
Did you often feel that: no one in your family loved you or thought you were important or special? Or your family didn't look out for each other, feel close to each other, or support each other?

YesNo
Did you often feel that: You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

YesNo
Were your parents ever separated or divorced?

YesNo
Were any of your parents or other adult caregivers: Often pushed, grabbed, slapped, or had something thrown at them? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

YesNo
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

YesNo
Was a household member depressed or mentally ill, or did a household member attempt suicide?

YesNo
Did a household member go to prison?

YesNo
Thank you for answering these questions. Your responses will help Bellis gain a better understanding of challenges you may have faced earlier in life and provide context for your experiences as an adult.This perspective can be especially helpful for healing.

If you or someone you know is in immediate danger, please call 911. If you are having thoughts of suicide or self-harm, please call or text the National Suicide Prevention Lifeline at 988. When you call, text, or chat 988, you will be connected to trained counselors who will listen, provide support, and connect you to resources, if necessary.

Please note: if your message to Bellis today describes that you are worried about your own safety due to thoughts of suicide or self-harm, Bellis may contact local emergency services to check on your welfare.

Bellis operates a mobile messaging program subject to these Mobile Messaging Terms and Conditions.

This Privacy Policy explains how Bellis collects, uses, and discloses personal information about our customers, prospective customers, and visitors to our website.
Record type
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Support Group Request Form

General Information Form

Adverse Childhood Experiences (ACEs)