Request edit access
Black Homeless Support
Collaborising is seeking 10 people who are currently unhoused to participate in a 6 week online transformative coaching and mindful wellness program.  Participants must currently reside in Richmond and agree to 1:1 individual coaching and group classes. The goal of the program is to help you prepare mentally and emotionally for housing as you wait for service providers to assist you in your search for housing.
Email *
Full Name *

Date of Birth

 *
MM
/
DD
/
YYYY
Email
 *

Phone number

 *

Name of Emergency contact & phone number

 *

Do you live in Richmond?

*

How would you describe your present circumstance? (encampment/ tent/ car/RV/ Couch surfing) Check all that apply.

 *
Required

Do you identify as Black?

*Collaborising does not discriminate on the basis of race.  However, Black people are disproportionately impacted by homelessness and systemic racism.  Our goal is to provide relief where society has failed. We will consider all applicants.

 *

This is a 6 week online program. Do you have access to Zoom by cell phone or computer?

 *
Required

Do you have reliable internet access either by cell phone or wifi?

 *

Can you commit to attending all group sessions and individual 1:1 coaching sessions?

 *

Are you receiving services from a homeless provider in Richmond?

 *

If yes, please state the name of the organization.

 *

Do you have a social worker?

 *

If yes, please state the name of the social worker AND their cell phone AND email.

 *

This program gives gift cards for participation.  Are you able to receive an online gift card?

 *

If you are not able to receive an online gift card we can provide a physical gift card at a later date?

*Please be aware that a physical gift card will not be available at regular intervals and may take up to 1 or 2 months to receive.

 *
If selected, do you prefer online or physical gift cards?
 *
Collaborising is a non profit agency. We are not therapists and we do not provide therapy or medical advice.  The coaching that we provide is not clinical and does not address mental health concerns. By checking this box you assert that Collaborising does not provide medical or psychological services.
 *
Required
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms