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Well Wishers
Formally recognized as the District 7780 Chapter of the Rotary Action Group- Mental Health Initiative, we are informally calling ourselves the "Well Wishers." We encourage community members to share their wishes for hope, healing and human connection. Through openness and commitment to services, well wishers have positive and lasting impacts on communities. This Action Group is open to everyone; please share your information if interested in well-wishing.
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Name *
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Rotary Club Member
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Vocation
Relevant experience with mental health:
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If professional, relevant license or certification:
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Comments- share additional related information here as needed.
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