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Caregiver Support Group
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone Number
*
Your answer
Who referred you to this group?
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Your answer
Email address of referral source:
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Your answer
What would you like to get from this group?
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A sense of community with other caregivers going through similar things
Education on sexual assault and the healing process
I don't know, I was referred by DHHS, LE, etc.
Other:
Are you are experiencing any crisis at this time that might make it hard for you to focus on issues relating to this group?
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Yes
No
Do you have a support person or therapist to talk to if this becomes upsetting to you?
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Yes
No
The group starts March 10rd, 2022 and lasts about 9 weeks. Will this timeframe work for you?
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Yes
No
No but add me to the waitlist for next session
Do you have access to a computer, tablet, or smartphone that you can access zoom to participate in the sessions?
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Yes
No
Your answer to this next question will only be used to help us accommodate any of your needs during the Caregiver Support Group. Will you need any accommodations in order to participate in the Caregiver Support Group?
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Yes
No
4.
Have you at any time been affiliated with the military?
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Yes
No
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