Long Covid Care Bear Time Form
Please fill this form out at least 48 hours before the start of your group. Thank you!
All responses will be confidential.

Note: Hiring ASL interpreters and/or live captioners requires advance notice and additional funding on my behalf (beyond the cost of this session). I will try my best to get this need met for the group if folks request it below or via email (my email is info@bsamimapothecary.com). I will reach out to participants with updates if this access need is requested, and updates on if I can meet this need in time for the session. 
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Name *
Pronoun/s (optional to share)
Email *
Access Needs 
(Examples of access needs: "I need to remain off video"
Please share any identities (for example: gender, race, sexuality, class, disability, religion/spiritual practices, etc.) you feel comfortable sharing here, so that I have a sense of who is joining this group
Would you like to be paired up with a buddy after the session? [The "other" space is in case you are not sure, if you have any requests, or if you have any questions about this] *
What are you hoping for in joining this group at this time? (Can be one sentence or word, or longer if you desire. We will dive into more of this during our time together) *
Additional comments/questions
(Or, feel free to email: info@bsamimapothecary.com)  
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