Resilience From Our Roots
This form is meant to provide some reflection and insight into your participation in this 10 week healing group for QTBIPOC focusing on developing and cultivating resilience. Thanks for taking the time to thoughtfully answer all questions. Participants will be notified of their acceptance into the group as soon as possible. If you have any questions please feel free to email us at
Email *
Preferred Name *
Gender Pronoun *
Phone *
Email *
How'd you hear about this group? *
How do you identify in terms of race, class, gender, sexuality, etc? What communities are you a part of? *
What does resilience mean to you? *
Why do you want to participate in this group? What are you expecting to learn? What do you want to be true after 10 weeks? *
What has your healing work looked like up to this point? How much intentional healing have you done? *
What is your support system like? *
How are you in groups? What kind of positive feedback do you get from others in groups? What about negative? How do you take feedback when you receive it? What edges do you anticipate bumping up against in this group? *
Do you have any access needs that we should know about? Access needs can be around things like chronic illness, particular scents, emotional experiences etc. What might help you be all in in this group? You're 100% at choice in what you share here.
This group runs 10 weeks, starting in March 2019 (exact dates dependent on enrollment) Group will be held in the Capitol Hill neighborhood of Seattle from 6-7:30 PM. Group members are expected to be on time and to attend all sessions. All absences must be prearranged with facilitator. Can you commit to this? If not, please explain. *
The cost of this group is $40/session or $400 for all 10 sessions. You are committing to full commitment of these 10 sessions and are responsible for payment, even if you miss a session. Is this a commitment you are able to make?
Anything else you want us to know?
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