FREE to Be Interest Form
Complete this form to express your interest in our supportive space for girls and young women. FREE to Be is a 12-week group program where girls and young women come together in a safe, supportive space to talk, learn, and grow. Each week includes real conversations, creative activities, and skill-building around confidence, relationships, and life decisions. The group is led by supportive staff and focused on helping participants feel heard, respected, and connected.
Full Name
*
First Name
Last Name
Preferred Name
Age Group
*
Please Select
10–12
13–15
16–18
19–21
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Best way to contact you
*
Call
Text
Email
Program Schedule
Are you available Tuesdays 4:30–6:00 PM?
*
Yes
Sometimes / need support
No
Are you available Thursdays 4:30–6:00 PM?
*
Yes
Sometimes / need support
No
Would you like to be contacted about future groups or different times?
Yes
No
Would transportation or scheduling support help you attend?
Yes
No
Not sure
About Your Interest
What interested you in FREE to Be?
What are you hoping to get out of this program?
Topics of interest
Confidence
Stress management
Relationships
Goal setting
School/career
Creative expression
Other
Support
Do you have a support person?
Yes
No
Prefer not to say
Would you like us to coordinate with your support person?
Yes
No
Support Person's Case Manager or Counselor Name
Support Person's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Support Person's Email Address
example@example.com
Anything we should know to support you?
Referral
How did you hear about FREE to Be?
School
Probation/Court
Community organization
Social media
Friend/family
Other
Were you referred by someone?
Yes
No
Who referred you?
Parent/Guardian Name
Parent/Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Participant Status
Please Select
New Lead
Consent Sent
Consent Received
Youth Form Received
Fully Enrolled
Submit Interest Form
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