Info-Cult Support group sign-up form / Formulaire d'inscription au groupe de soutien d'Info-Secte

Questionnaire for People Wishing to Participate in the Support Group for Former Members
This form serves to help us assess whether this service meets your needs and expectations. Since the goals of this support group do not suit all situations, we may suggest other resources.

The information you provide in this form is collected and used by Info-Cult solely for the following purposes:
- to evaluate if this support group meets your needs;
- to contact you regarding your registration;
- to manage your participation in meetings.
All responses will remain confidential.

Please note that we are able to accommodate a maximum of ten (10) participants per meeting.
Name*

First NameLast Name
Gender
I am 18+ years oldI am under 18 years old
Birth year
YYYY
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: +0 (000) 000-0000.

Please do not include detailed or unnecessary medical or legal information.
Please describe your experience, in brief.*
When was your experience?*
Date range
Are you receiving, or have you ever received, other forms of professional help relating to this experience? If so, when?
Why do you want to participate in this support group?*
Is there anything else you would like us to know?

Protection of Personal Information
In accordance with Act 25 and Info-Cult's Privacy Policy, your consent is required so that we can process your personal information in a transparent, secure and respectful manner.
I have read and understand Info-Cult's Privacy Policy, and consent to my personal information being processed in accordance with it. * I understand that my information may be retained after my participation to allow for follow-up or to be recontacted as needed, in accordance with the organization’s information retention policy and regulatory requirements. *
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Questionnaire for People Wishing to Participate in the Support Group for Former Members