MMIP Peer Support Group Registration
Zoom link information will be sent to you after you submit this form.
Group Member Information
Name
*
First Name
Last Name
Name of MMIP Loved One
First Name
Last Name
Location
*
Email Address
*
example@example.com
If you would like to receive an Honoring Kit, please fill out the information below.
Participants are asked to attend the peer support group when requesting an Honoring Kit, as the meeting will include guidance on how to use the kit. Honoring Kits will be mailed out prior to the meeting and must be requested one week in advance to ensure timely delivery.
Will you be attending the upcoming MMIP Peer Support Group?
Yes
No
Do you have any allergies?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I will adhere to the Empowerment Advocate’s confidentiality agreement, which will be provided to me prior to the upcoming support group meeting.
*
I agree
How did you learn about the MMIP Peer Support Group?
Facebook
Instagram
Search Engine
Referral
Other
Any additional comments or information you would like to share?
Enroll Now
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