Healers & Clergy Triage Provider Network Questionnaire
For those that want to offer care remotely in the aftermath of Charlottesville to activists and community members impacted by the brutality. Please fill this out to let us know what you availability is, capacity is and (also) willingness for additional training as we begin to think about how to create a network that can support these kinds of triage-like events in the future specific to organizing and activism trauma response.

Folks supporting organizing this include a number of individual healers and clergy, Auburn Seminary, Faith Matters Network, Mystic Soul Project, Center for Inclusivity and Standing on the Side of Love in collaboration with Congregate CVille. We will not share your information with other outside outlets and will be using your details specifically for the purpose & mission of this Healers & Clergy Triage Provider Network.

Name: *
Your answer
Pronouns: *
Your answer
City: *
Your answer
State: *
Your answer
Contact Info: (email, phone, etc) *
Your answer
Website or Social Media Details (you want shared with your contact info): *
Your answer
Professional Degree/Title: *
Demographics (gender, sexuality, ethnicity, etc): *
Your answer
Do you have experience providing support to activists in any of the following ways? *
Required
Skills & Areas of Expertise: *
Required
What are your spiritual care skills? Do you work within a spiritual or religious tradition? If so, what? Do you work with tribal/indigenous/ancestral spiritual tradition work? *
Your answer
Are You A Trans/Queer Inclusive Provider? *
Remote Care Capacity: *
ASL Capacity *
Bilingual Support *
Willingness for Additional Training (Re: Trauma & Activism Intersections) *
Required
Pro-Bono Capacity *
Other Relevant Information: *
Your answer
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