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Survivors Healing Center Support Group Form
Please fill out this form if you are interested in joining a Survivors Healing Center Support Group
**Only the questions with asterisks are required - all others are optional**
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Email
*
Your email
Full Name
*
Your answer
Address
Your answer
Zip Code
*
Your answer
Phone number
*
Your answer
OK to leave message?
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No
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Email address
Your answer
Date of birth
*
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YYYY
Ethnic group
White
Hispanic or Latino
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
Other:
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Gender
Your answer
Household income
Your answer
Number of people in household
Your answer
Support Group that you are interested in joining
*
Women's Group (via Zoom) *Open to all who identify as a woman* *California residents only*
Somatic Group (in person, downtown Santa Cruz)
Gender Inclusive Somatic Group (in person, downtown Santa Cruz) *open to all gender identities including those that do not fall exclusively in man/male or woman/female categories*
Men's Group (open to all who identify as a man)
Equine Healing Group (in-person, Felton)
Mothers of Survivors Group
Spanish Speaking Women's Group (waitlist)
Spanish Speaking Men's Group (waitlist)
Expressive Arts Group (waitlist)
Teen Group (waitlist)
Other:
What type of support group would you like to see that is not on our list?
Your answer
Comments
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