Language
English (US)
Español
Daughters of Lineages Group: Interest & Waitlist Form
This form is a gentle first step. You’re welcome to share only what feels comfortable.
Full Name
*
First Name
Last Name
Preferred Name (if different):
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Are you 18 years or older?
*
Yes
No
Do you identify as a Black woman or a woman of color?
*
Yes
No
I Prefer Not To Say
What is drawing you to the Daughters of Lineages group at this time?
*
Have you participated in therapy or a therapeutic group before?
*
Yes
No
I Prefer Not To Say
The group fee is $60 per session (self-pay). Does this feel accessible for you at this time?
*
Yes
Possibly
No / Would like to discuss
Is there anything you’d like the facilitator to know as we prepare to open this group?
By submitting this form, I understand that joining the waitlist does not guarantee placement in the group and that a brief screening process may be required prior to enrollment.
*
I agree
Would you like to receive updates about future groups or offerings?
*
Yes
No
How did you hear about us?
*
Please Select one
Referred by a therapist or healer
Shared by a friend or community member
Social media (Instagram, Facebook, etc.)
Website
Community event or gathering
Newsletter or email update
Word of mouth
Other
If other, please specify.
Save
Submit
Should be Empty: