The Healing Portal
Time: 1PM - 2:45PM
Location: 304 N. 6th St., San Jose, CA. 95112

Kick-Off: Sat, Dec 13, 2025
Session 1: Sat, Jan 10, 2026
Session 2: Sat, Feb 28, 2026
Session 3: Sat, Mar 28, 2026
Session 4: Sat, Apr 18, 2026
Sign in to Google to save your progress. Learn more
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Email  *
Address *
City *
Zip Code *
Ethnicity/ Race *
Emergency Contact Name *
Emergency Contact Phone Number *
  Have you ever participated in a support or therapy group before?   *
  What brings you to this group? (e.g., stress, grief, anxiety, self-esteem, relationships)   *
How would you like the facilitator to support you if you become overwhelmed?   *
Is it okay for the facilitator to follow up with you individually if needed (e.g., check-ins, resources)?   *
Do you understand and agree to maintain group confidentiality?   *
Do you consent to photo and video? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of African American Community Service Agency.

Does this form look suspicious? Report

Google Forms