MM Core Group Program Application Form
Please complete this form to join the MM Core Group Program. Your answers will help us match you with the appropriate Core Group.

All of this information will be kept strictly confidential and not shared with any source outside of the Core Group Administrators and MM Executive.

Your email address will be given to other members of the Core Group you are assigned to in order to establish your group communication.
Sign in to Google to save your progress. Learn more
Email *
What name/pseudonym/nickname would you like to use when interacting with your Core Group? *
How did you find out about Moderation Management?
Clear selection
How long have you been a member of MM? *
What MM communities have you been actively involved in since joining? (Check all that apply) *
How do you think YOU will benefit from being part of the MM Core Group Program? *
How do you think you will benefit OTHERS from being part of the MM Core Group Program? *
How many hours per week do you think you will want to engage with your MM Core Group? *
What is your preferred method of communicating with your Core Group? (Check all that apply) *
What time zone are you located in? (If you're not sure, please indicate what country/state/province/region you are located in.) *
Please provide your age range *
Please indicate your gender *
Do you identify as belonging to the LGBTQ Community?
Clear selection
Are you open to a mixed gender group?  *
If you have children, what are their age ranges? (Check all that apply) *
Is your spouse/significant other supportive of your moderation efforts? *
Does your spouse/significant other also struggle with alcohol use? *
Do you struggle more with binge drinking or everyday alcohol use? *
Are you currently focused on moderation or abstinence? *
Please provide the name and mobile phone number of an emergency contact. Although this is not mandatory, we encourage participants to provide this information as an extra measure of safety in the event of a crisis.(Note: We will only use this information if we believe you are in danger of being harmed, harming yourself, or harming another).
Is there someone (or a group of people) in particular that you would like to be in the same Core Group with? If so, please provide the name they go by or the group you'd like to be matched with.
Is there anything else about your relationship with alcohol that you think we should know to help us match you to your MM Core Group?
I agree to the Core Group Program Guidelines outlined in the following document: Core Group Program Overview & Guidelines *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy