Healing Circles Request Form

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Thank you for your interest in holding a virtual Healing Circle for Change.

Email *

Your name (and role in the organization, if applies) *

Your organization's name *

Your website link (if applies) *

If you don't have a website, please describe the mission of your group

Your cell phone number *

Tell us why you are interested in holding a Healing Circle. *

When are you hoping to hold a Healing Circle? *

If you aren't sure on the exact date, please provide a rough estimate of the specific month or time of year (fall, winter, spring, summer).

Roughly how many people do you expect to attend the Healing Circle? *

Tell us more about what topic you are hoping to focus on during this Healing Circle (if known). *

How did you hear about our Healing Circle format? *

Thank you. Someone will email you shortly to set up an intake meeting.

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