The Survival Guide Cohort: A Sanctuary of Resilience, Refinement and Renewal for Black Women.
Application Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
What is the best way to contact you
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email
telephone
text
Best time to contact you
Please Select
Early Morning (6 AM – 9 AM)
Late Morning (9 AM – 12 PM)
Early Afternoon (12 PM – 3 PM)
Late Afternoon (3 PM – 6 PM)
Evening (6 PM – 8 PM)
Anytime
How did you hear about us?
*
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Social Media
Email
Facebook
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Other (Please specify...)
What are the White Spaces you experience the
Work Place
Neighborhood
Faith Community
Recreation Places
Social Groups
Schools
Family
Other
What would you say the most pain point you deal with most frequently
Microaggressions
Isolation and Loneliness
Being underestimated
White Fragility
Stereotypes
Feeling pressure to represent your entire group
What are your personal goals if you participate in the Survivial Guide Group Coaching
I am glad you are taking this important step toward your peace. I would love to talk with you more about your goals and hopes for the program. Please take a minute to schedule a call below.
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