Healing Through Change, Inc.
Support Group Registration Form:
Welcome! We at Healing Through Change, Inc are delighted that you are interested in our in-person/online support groups. For your safety we require you to complete this registration form. It will only take a few minutes.  
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Today's Date *
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Name: *
Email Address: *
How did you hear about Healing Through Change's In-Person/Online Support Group? *
Are you interested in In-person or online support groups? *
Required
Please Choose the support group you would like to attend. *
Required
Age Group *
Home Address *
If you experience an emergency during an online support group would you like us to contact someone? *
Required
Would you be interested in a future support group for parents of youth and teens who identify as Transgender and Gender Nonconforming ?
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I promise to adhere to the guidelines presented at Healing Through Change, Inc Support Group: {INITIAL BELOW} *
I understand that Healing Through Change, Inc support groups are confidential unless facilitators believe I am in danger of hurting myself or someone else. If a facilitator is worried about my safety they will contact the crisis unit and my emergency contact.  I realize this is to protect me and keep me safe: {INITIALS ONLY} *
I give Healing Through Change, Inc. permission to send me emails (I can opt out at a later time): *
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