R.I.S.E Support Group Registration Form
Essence of Mind Outreach is providing a free support group for women in the community in hope of addressing some of the mental health issues we are facing. These include personal challenges, lived experiences with mental health and health-related issues as well as traumatic experiences. We welcome all who are seeking support and aim to provide an empathetic, safe and confidential place where we can share, connect and offer support or assistance as needed. We endeavor to offer ways of finding personal strength and resilience through connection, empowerment and education. Please fill in your details below to register for this unique and valuable opportunity.

The program will run from March 12th - May 28th 2019 (alternating Tuesdays) at Grace Place, 156 Main St N, Brampton, ON L6V 1N9.

By completing the form below, you are agreeing to subscribe to our emails announcing upcoming events and programs. We promise to keep your information confidential and will not share your information with other parties without consent. You will be able to opt out of emails at a later time, if you wish to do so.

Email address *
How do you identify yourself?
Name: *
Your answer
Contact Number: *
Your answer
Do you require any special accommodations at the venue? Please include any recent injuries and allergies.
Your answer
We'd like to know you a little so we can properly support you. What are you hoping to learn or gain from this support group? Do you have any expectations? Why are you attending? *
Your answer
Thank you for your registration and we look forward to welcoming you.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service