Widowed Separated Divorced Support Group Inc. Enrolment Form.
Details given on this form are strictly confidential and are used for the purposes of support only.

Fee $100 or $80 for Community Services Card holders. Please pay prior to the commencement of the course or at the first session. (Please note – the payment includes your first year’s annual subscription to WSD.)

Name of bank account: WSD Support Group
Account number: 03 0510 0730257 00
Please include your name in the Reference field.

Email address *
Surname: *
Your answer
First name (s): *
Your answer
Date: *
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YYYY
Date of birth or approx. age: *
Your answer
Address: number and street, include suburb and postcode. *
Your answer
Phone: home
Your answer
Phone: mobile
Your answer
Your current status: *
Widowed/separated/divorced since: *
Your answer
Relationship history: name of ex-spouse/partner, years together, any other comments: *
Your answer
Children (names and age of children, if part of the situation you are working through:
Your answer
How are you managing? Select the option which best describes where you are at: *
How are things affecting you? What is affecting you the most? eg loneliness, loss and grief. *
Your answer
What topics are you interested in? eg adapting to your new life, peer support. *
Your answer
How did you hear of WSD? Tick more than one if applicable: *
Required
Agreement - I expect that my privacy will be protected and I agree to protect other participants' private information. Full name: *
Your answer
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