Request edit access
ETV Women's Healing Circle Interest Form
Welcome! Thank you for your interest in Empower The Village's (ETV) Women's Community Healing Circle! The Healing Circle is part of the ETV's Village Assist Program that aims to be a safe, inclusive space for Black women to explore and discuss their feelings, challenges and triumphs in a supportive setting led by expert therapist Dr. Cassandra Hutchins. 

This form serves as pre-registration for the Healing Circle. It will be submitted to the lead therapist, and you will be contacted to set up a brief 1:1 intake session to assess whether the Circle would be a fit to address your needs and to share the schedule. If you have any other questions or concerns, please contact us at admin@empowerthevillage.org. 

Thank you for taking this important step towards achieving a more peaceful, joyous and balanced life! We look forward to you joining us. 
Sign in to Google to save your progress. Learn more
Name *
Email *
Phone number *
Do you prefer to be contacted via email or cell phone (text message)?  *
Required
Your zip code  *
Thank you for submitting the interest form! You will be hearing from ETV staff and/or Healing Circle facilitator to schedule your intake session shortly. 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms