Oncofertility Huddle Support Group Interest Form

Oncofertility Huddle Support Group Interest Form

Share a few details to help us better understand your needs. To completing this form, I am expressing interest in joining a group with Worth the Wait. Our next cohort will meet on Oct. 6, Oct 20, Nov 3, Nov 17, Dec 1 and Dec 15 from 4-5 ET. Please only apply if you are able to attend these dates/time.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age
State of Residence
What is your gender?
Sexual Orientation
Relationship Status
How do you racially identify yourself?
What type of cancer do/did you have?
I am a patient/survivor...
What was your age at your initial diagnosis?
Where are you in your family building journey?
If I am selected for this huddle, I can commit to attending each of the sessions: Oct. 6, Oct 20, Nov 3, Nov 17, Dec 1 and Dec 15 from 4-5 ET/3-4 CT/2-3 MT/1-2 PT.
Do you have a child (biological, stepchild, foster child, adopted)?
I understand that this Support Group is NOT therapy. If I would like a referral to establish care with a mental health therapist, I will contact Worth the Wait who can assist in this process.
I understand that Worth the Wait facilitators are mandated reporters. If information is shared relating to abuse/harm to a child, elder or vulnerable adult, or if someone indicates they are a danger to themself or others, the facilitators will report this information to the appropriate agency to provide support and follow-up.
I understand that there are risks, benefits, and consequences associated with participating in a virtual support group including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
Support Group Expectations: As facilitators we empower group members to take the lead in directing the flow of group. Your lived experience and unique lens provides necessary validation and connection with each other. By putting group members in the driver's seat, you can ask each other relevant questions, normalize each other's feelings, and share resources that you've found to be helpful.We know that making time commitments is hard, however, we also believe that in making the commitment fully, you will receive the most benefit and provide the most support to our community. To that end, we ask you to please:• Join on time with the intention to stay the whole meeting.• Come to the group solo • Concentrate fully on the meet-up group. Please do not make us background to another task. For safety, please do not drive during group--if this is necessary, please turn off your camera so you can keep your eyes on the road. • In support of everyone’s emotional needs, please remember that this is a group for oncofertility and family building after cancer, which everyone handles differently. To that end, we ask that you please:• Practice reserving judgement: listen openly, respect intentions, and appreciate the opinions and thoughts of everyone, including those you disagree with.• Keep issues relating to politics and religion specific to how it is affecting your cancer experience. Please refrain from preaching our pushing your beliefs on anyone else in group. • Share your thoughts and share the space for others to do the same.
Please explain where you are in your family building process and your future plans.
Have you participated in therapy in an individual or group setting before?
What do you hope to get out of this experience?
Anything else you'd like us to know.
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