IDG Wellness Program Interest Form

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Please fill out this form if you are interested in our support groups and short-term emotional and practical support. We will follow up with you within two working days. We will also be offering free individual, couple, and family counseling, as well as help accessing benefits in the near future, and we will contact you when these are available.

What IDG Wellness programs are you interested in? *

Support groups

Short-term emotional and practical support

Assessment and referral to other social services

Individual, Couples and Family Counseling (Coming soon!)

Help accessing benefits: SNAP/EBT/Food Stamps, healthcare, etc. (Coming soon!)

Other:

Required

First Name: *

Last Name: *

Phone Number: *

Email: *

ZIP Code *

Preferred Language: *

Are you able to complete counseling and/or discussion circles in English? *

Yes

I am not sure

How do you prefer us to contact you? *

Phone

Either phone or email

Is there anything else you'd like us to know?

Submit

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