Youth Era's Transmasc Peer Support Group Intake Form

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Please fill out the form below so we can get to know you a little more!
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Current Group Schedule:
Virtual meetings on the 1st and 3rd Wednesdays of every month from 6:00 - 8 pm Pacific Time on Discord.

This group is for ages 18 - 25. This Transmasc Youth Adult Peer Support group is led by other peers and is a space to connect, vent, and support one another.
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This information is confidential and will only be used by Youth Era staff to ensure you're best supported in this group.
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For more information about Youth Era, please visit https://www.youthera.org.

First Name *

Last Name *

Pronouns *

How do you identify? *

For example, transman, nonbinary, genderfluid, queer, etc.

Email *

Phone Number *

Birthday *

YYYY

Emergency Contact: Name, Relationship, Phone Number

For example, Cheryl Jones, Mom, 503-555-1234. By sharing this information, you give Mordekai permission to reach out to your emergency contact if you are in a crisis situation and need help staying safe. In honoring your process and out of respect, Mordekai will do his absolute best to have a conversation with you before making a call to your emergency contact.

What are you hoping to gain from this group? *

Please share any goals, intentions, or expectations you have in joining this peer support group.

I agree to meet with a Youth Era staff member over Zoom prior to the first group I attend. *

This step is required to ensure the safety of all members. This also gives you a chance to learn more about the group and the culture we hold in it. This will take about 15 minutes.

Yes

Please share any comments or concerns you have about group, or any information or accommodations you think are important for me to know before you join us

Thank you for sharing! Please keep an eye out for an email asking you to schedule your Zoom call with a Youth Era staff member.

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