Diabetes Self-Management Support Program Intake Form
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  • We have culturally tailored a program just for Black women.

    BUT IT TAKES A VILLAGE!

    Grab a friend or family member and join the Black Women's Health Imperative's (BWHI) Diabetes Self-Management Support Program now. Participating in one of our support groups will give you a trained Lifestyle Coach, along with the tools, information, and support you need to live your best life while managing type 2 diabetes. 

    Get started now by answering a few questions below!

  • Do you agree with the following statements? 

    1. I have been diagnosed with type 2 diabetes 
    2. I am 18 years or older 
  • Are You at Risk for Type 2 Diabetes? 

    Thank you for your interest in the Diabetes Self-Management Support Program. Unfortunately, it doesn't look like you are eligible to participate in this program.  If you are at risk of developing type 2 diabetes we would like to invite you to participate in our diabetes prevention program.

    Click here to take our 1-minute risk test to see if our diabetes prevention program is right for you!

     

    Would you like to stay in touch with BWHI?
    Submit your contact information on the next page to get information about the BWHI app and public community!

  • Tell Us More About Yourself 

    Overall Instructions: Please read the questions completely before answering. All information provided is confidential.

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  • Diabetes Self-Management Support Program


    Class Days and Times
    Please indicate which days and times work best for your schedule, keeping in mind that the program will meet weekly for 10 weeks. We will make every effort to accommodate your preference. You will receive an email confirmation regarding your class. Please be aware that all dates and times are subject to change.

    *New classes are added periodically*

  • Thank you!

    By clicking submit, you agree to receive information from the Black Women's Health Imperative.

    Click the submit button below to complete your submission.

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