🦋 Find My Freedom – Program Registration Form 🤍
✅ SECTION 1: About You
Name
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Email
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Phone Number (optional)
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Location (Suburb/Town & State)
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Are you over 18 years of age?
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Yes
No (Unfortunately, this program is currently for 18+ only)
📱 SECTION 2: Social Media Handles
Instagram Handle
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Facebook Profile Name
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TikTok Handle
*
Other Social Media (optional – e.g., Threads, Twitter/X, Snapchat)
*
🌻 SECTION 2: Where You're At in your Journey
Are you currently: (tick all that apply)
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I’ve just left an abusive situation
I’m preparing to leave
I left some time ago and am now rebuilding
I’m not sure where I’m at
If you selected other please specify, simply type n/a if not applicable!
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Have you accessed support before (e.g. counselling, DV services, community groups)?
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Yes
No
Not sure/ Prefer not to say
Do you have current safety or legal concerns (e.g. active AVO, stalking, unsafe housing)? (This helps us know what support or referrals you may need — it's completely confidential.)
*
🌼 SECTION 3: About the Program
What made you want to join the Find My Freedom program?
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Which phase do you feel most aligned with right now?
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Phase 1: Immediate Safety & Support
Phase 2: Reclaiming Identity & Healing
Phase 3: Full Empowerment & Transformation
I’m not sure — I trust the team to guide me
Are you here for: (tick all that apply)
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In-person group sessions
Online community support
Information & resources
1:1 support (where available)
I’m just exploring
In-person sessions (Byron-based only)
All of the above
How would you like us to support you in this space?
*
🦋 SECTION 4: Our Values
✨ Honesty – We value openness and transparency in sharing experiences, challenges, and progress. 🗣️💬💖 Compassion – Empathy, kindness, and a non-judgmental approach guide us as we support one another on our healing journeys. 🤝💕🤝 Respect – Everyone deserves dignity and understanding. We honor diverse experiences and perspectives. 🌍✨✅ Accountability – We take responsibility for our growth and actions, helping each other build healthier, thriving futures. 🌱💪🔒 Confidentiality – Your stories and experiences are safe here. What’s shared in this space stays in this space. 🛡️🤫💪 Strength – We celebrate resilience and the courage it takes to overcome challenges. Together, we grow stronger. 🦋🌟🌈 Positivity – We focus on healing, progress, and the potential for a brighter future. Optimism leads the way! 🌞🌼💬 Supportiveness – We uplift one another, offering help, encouragement, and knowledge wherever we can. 🤗💡✌️ Non-Violence – Peaceful, respectful communication is essential. Aggression, discrimination, or harm has no place here. ✋❌🤗 Inclusivity – We embrace diversity, creating a welcoming and accepting space for everyone. 🌈✨This is a safe and loving community. Let’s work together to maintain these values and uplift one another. 💕You are brave. You are strong. And you are so loved in this space.With love,Loz and the Team at Find My Wild 🤍🦋
Do you agree to uphold these values while in this space?
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Yes
No
Do you agree to participate in this space with honesty, compassion, and respect for others?
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Yes
No
Do you understand this is a confidential space and agree not to share others' stories or identities outside of the group?
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Yes
No
Is there anything else you’d like to share with us before we begin?
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✅ Final Confirmation
I understand that this is a survivor-led program and that the team may remove participants if values of kindness, safety, and respect are not upheld.
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I understand
I understand that this is not a crisis support service, this service is run by survivors and no advice (only referrals and experience will be provided). I know where to seek emergency help if needed.
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I understand
Submit
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