The Hope Circle Registration Form

The Hope Circle

Intake & Confidentiality Form
Section 1: Participant Information
Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is this registration for?

A girl (ages 10–17)A woman (18+)Group
Section 2: Emergency Contact
Contact Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Section 3: Background & Support
1. What are you hoping to gain from participating in the Hope Circle?*
Section 4: SAFETY & CONSENT
I understand that The Hope Circle is a supportive, group-based experience and is not a replacement for professional counseling or therapy.*

Yes, I understand.
CONDITIONAL CONSENT (FOR GIRLS ONLY) I give permission for my child to participate in The Hope Circle, hosted by Hope S.A.V.E.S.H.E.R.*

Yes, I give consent.N/A
Signature*
Date Signed*

MonthDayYear
Date
Should be Empty:

The Hope Circle