Trans*cend the Binary Youth Peer Support Group Intake Form

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Welcome!

The Trans*cend the Binary Peer Support Group is for youth ages 14-17 who identify as LGBTQIA+, queer, and/or questioning. Together, we are creating a space to connect, share our experiences, and receive support along the way.

To join, please fill out the form below so I can get to know you a little more!
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To ensure the safety of all individuals participating, I ask that we meet very briefly on Zoom before your first group so that we can get to know each other, go over the needs and wishes you have in attending group, and to familiarize you with the flow of how the group is ran.
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Current Group Schedule:
Meeting on Zoom on the 1st & 3rd Thursday of the month from 4:00 - 5:30 pm Pacific Time
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This information is confidential and will only be used by the group facilitator, Mordekai Tawney (he/they), to ensure you're best supported in this group.

For more information about Youth Era, please visit https://www.youthera.org. You can also contact Mordekai directly via email at mtawney@youthera.org or text/call at 541-510-5841.

First Name *

Last Name *

What pronouns should I use with you? *

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 Mordekai, the group facilitator, over Zoom prior to the first group I attend. *

This step is required to ensure the safety of all members. This also gives Mordekai, the group facilitator, a chance to learn more about you and your needs while familiarizing you with the technology and the flow of the group.

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 me.

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