Healing Ourselves: Victims of Crime Support Group - Application Form
All information will be kept confidential and used solely for administrative purposes. Your data will not be shared without your consent. If you have questions, please call us at: (805) 323-6156
Email address *
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Cell Phone *
Your answer
Email *
Your answer
Preferred Method of Contact? *
Work Phone
Your answer
Occupation *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender Identity *
Primary Language *
Any limitations or disabilities we should be aware of? *
Briefly describe the crime that impacted you (example: I was robbed by several teens in a physical attack) *
Your answer
When did this occur? *
Your answer
Were the police involved? *
Has the case been tried and settled? *
Did you seek counseling for this incident? *
Have you ever been under the care of a mental health provider for any reason (such as a therapist, psychologist or psychiatrist)? *
Do you have children that will require babysitting so that you can participate? (Please note the babysitters will be volunteers who have been screened and trained. Babysitting will be on the premises of the group in a nearby room). *
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