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Thank you for your willingness to join this support group and to share more about your situation. If you provided contact information, a facilitator will follow up to ensure this group is a safe and appropriate fit for your needs.

Please note this is a non-clinical support group hosted by educational nonprofit organization Yoga to Cope. Confidentiality is a priority, though sessions will not be HIPAA-compliant. On approval to participate in the group, participants will be expected to acknowledge and uphold the organization's confidentiality and community agreements to ensure the safety and security of all members. Any violation of such will be cause for immediate removal from future group sessions.  

Please reach out to hello@yogatocope.org with any questions, comments, or concerns. 


First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Third Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Parent or Guardian's Email Address
Email*
Confirm Email*
Safety and Background Questions
Are you currently involved in any active criminal proceeding(s) related to domestic violence(DV)?*
Yes
No
Unsure

Please provide and information relevant to the above question: 

Has the DV relationship concluded within the last 3 months?*
Yes
No
If not, are you currently in contact with the person who caused harm?*
Yes
No
Do you have children involved or affected by the DV situation?*
Yes
No

If yes, please describe briefly:

Are you currently in a safe living situation?*
Yes
No
Do you have any other ongoing safety concerns?*
Yes
No

Please describe briefly:

Have you participated in individual counseling or support groups before?*
Yes
No
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Participant's Address
Address Line 1:
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:
City:
State/Province:
Zip/Postal:
Support Needs & Group Fit
What are you seeking support for the most?
Do you have any accessibility needs or accommodations?
What interests you about joining this support group?
Is there anything you would like the facilitator to know ahead of time?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Information
Preferred Name + Pronunciation
Pronouns
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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