DV Survivors Parent Support Group
Interest Form
Thank you for your interest in the Parent Support Group for Domestic Violence survivors.
Name and pronouns:
*
Please ensure that you provide at least one of the following methods of contact so that group facilitators can reach you with the meeting link
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Is it safe to contact you at the above?
Yes to texting that phone number
Yes to calling that phone number
Yes to email
Ages of the children you are caring for:
Check all the apply:
*
My family has been impacted by some form of domestic violence
I want support parenting or caregiving for a child who has been impacted by DV or other forms of trauma
Here are the group agreements, please check box next to each to indicate you have read and understand them.
*
Participate in whatever way that honors you - you don't have to have your camera on if it doesn't feel comfortable or safe to do so, you can use your initials instead of your name if that feels safer for you
We will interrupt speech that is racist, sexist, transphobic, etc.
This group is a confidential space, we will work together to protect each other's privacy
This group is intended to focus on parenting concerns, questions, and experiences as survivors
I understand that all Impact NW staff are considered Mandatory Reporters and are required by law to report alleged abuse and/or neglect of: children, adults age 65 and over, adults with physical or developmental disabilities and/or mental illness, and residents in nursing or care facilities.
*
Yes
I have more questions about this and I'd like one of the facilitators to contact me directly to discuss further
If you have additional comments, questions, or concerns, please include them below and we can reach out to you directly via the phone or email address provided above.
The first group will be held November 21st from 12:30-1:30pm on Zoom. We will be meeting every other Friday. We will text and/or email the zoom link and reminders about future groups, including changes to schedules due to holidays.
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