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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
*
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.
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