Intake Step 2

You are on the path to support. To link information across survey submissions be sure to give the same email address on all forms.

To move your INTAKE forward you must accomplish 3 survey forms:

1. Group Intake Survey - approximately 5 minutes

2. Emotional History Survey - approximately 5 minutes

3. Income Questionnaire - approximately 3 minutes

Once all surveys are accomplished, please complete the below items and SUBMIT BELOW... which will result in the 3rd and final step in this INTAKE process ~ an appointment to have a real conversation with a Healing Justice provider.

First Name

Last Name

What is your birthdate?

I accept that all participants in this program will attend Group Meetings and I have completed the Group Intake Survey Form

I accept that admission into this program requires me to disclose facts about myself and I have completed the Emotional History Survey

I accept that admission into this program is based on financial capacity and I have completed the Income Questionnaire

I affirm that the email address used on all forms is listed above and that I will be on the lookout for INTAKE STEP 3 to arrive at that email address

INTAKE STEP 2 was submitted!

Click Here To Request An Appointment

INTAKE STEP 2

If you are in crisis or in need of immediate support, please call:

The National Suicide Prevention Lifeline 1-800-273-TALK (8255)