Support Group Waitlist Application
Apply to join our support group waitlist. Please provide your information and preferences so we can match you with an appropriate group when space becomes available.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
Female
Male
Non-binary
Prefer not to say
Other
Preferred Support Group Type
*
Grief Support
Mental Health Support
Addiction Recovery
Caregiver Support
Other
Why do you want to join a support group?
*
Preferred Meeting Format
*
In-person
Online
No preference
Availability (Select all that apply)
*
Weekday mornings
Weekday afternoons
Weekday evenings
Weekend mornings
Weekend afternoons
Weekend evenings
Have you previously participated in a support group?
*
Yes
No
How did you hear about our support group?
Friend or family
Healthcare provider
Online search
Social media
Other
Is there any additional information you would like us to know?
Submit Application
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