Support Group Interest Form
Thank you for your interest in the trauma-informed support group. All information will remain confidential and completing the form does not guarantee participation in the group. Our first session is now full and we are on a waiting list for the next session (dates TBD). Please complete the form to be placed on the waiting list. We will be in touch shortly with more details once we receive your completed form.
Name
*
First Name
Last Name
What is your preferred mode of communication?
*
Email
Cell Phone/Text
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What is your age?
*
Are you female or female-identifying?
*
Yes
No
Have you experienced trauma?
*
Yes
No
Are you currently safe from harm?
*
Yes
No
Healthy Families Information
If you need immediate assistance, please call the Healthy Families 24/7 Crisis Line at 360-452-4357, call 911, or go to the ER.
In the past week, have you been having thoughts of killing yourself?
*
Yes
No
Suicide Prevention Information
If you need immediate assistance, please call the Clallam crisis line at 888-910-0416, call 911, or go to the ER. You could also text "home" to 741741. You may also call the National Suicide Prevention Hotline at 988.
Do you have a plan to commit suicide?
*
Yes
No
Do you intend to follow through with you plan?
*
Yes
No
Do you have a safety plan, therapist, or support?
*
Yes
No
What would make you stop and change your mind?
*
In the past week, have you been having thoughts or actions of hurting yourself in non-deadly ways, like cutting, hitting, or burning yourself?
*
Yes
No
What actions have you taken or do you plan to take?
*
Do you have a therapist or support?
*
Yes
No
What do you hope to gain from this support group?
*
Are you ready to participate in a group setting, to be vulnerable, and to be respectful of others' needs for a safe space?
*
Yes
No
Are you committed to attend all 12 sessions?
*
Yes
No
Do you require childcare to attend all 12 sessions of the support group?
*
Yes
No
How many children?
*
What are their ages?
*
How did you hear about the support group?
*
Submit
Should be Empty: