Women's Empowerment Support Group
Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Name
What are your pronouns?
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is it safe for us to call this phone number and leave a voicemail?
Yes
No
Call, but DO NOT leave a voicemail
Email
example@example.com
Is it safe for us to email you information about upcoming meetings?
Yes
No
Yes, but do not disclose counseling information.
Zip Code
*
If you do not have a permanent address, please use your best guess of a zip code that you reside in most.
Which of the support group meetings will you attend? (Please select all dates you plan to attend).
*
10/21 - Relationships and Boundaries
10/28 - Stress Management
11/4 - Emotional Processing
11/18 - Self Advocacy
12/2 - TBD Based on Group Interest
12/9 - TBD Based on Group Interest
Feel free to leave suggestions for topics to focus on in the final 2 sessions below!
Any food allergies? (We hope to provide light snacks for meetings).
*
Anything else you would like us to know?
Submit
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