Support Group Intake Form
Fields marked with an
*
are required
Financial assistance is available!
Are you seeking financial assistance? *
No
Yes
Grant Eligibility Worksheet
Please fill out this section to be considered for financial assistance
Number in Household
under 18
18-59
60 & over
Marital status
Married
Single
Divorced
Legally separated
Employer (if applicable)
Please enter your income using gross amounts (before taxes are taken out)
Welfare (Public assistance)
SSI
Social Security
Social Security Disability
Veteran's benefits
Pension
Unemployment
Child Support
Rental Income
Other Income
Briefly describe your reason for applying for this grant
First Name *
Last Name
Email *
Phone *
May we contact you at the information above? *
Yes
No
Are you currently involved with your partner? Please (briefly) explain your current living situation: *
Is there currently or has there even been Orders of Protection in your relationship? Are you currently in court for any reason? *
What are you hoping to derive from attending this support group? What are your goals? *
Is there any other information that you would like to share with our mental health counselors that may be relevant to your personal situation or your involvement in this group? *
Please initial the following statements to indicate your understanding and consent: *
This support group runs for 6 consecutive weeks. Support group dynamics are such that regular attendance is essential for all members to derive the most benefit. I am prepared (absent unanticipated emergency) to commit to attending all 6 sessions. I understand that if I fail to attend that payment is non-refundable.
Center for Hope WNY does not make any guarantees that services will have benefits. This group is psycho-educational and each person who attends may experience different results.
I understand that the identity of any person attending this group, the location of the group and the content of anything discussed in group is confidential and may not be disclosed or shared with anyone outside of the group.
I understand and agree that all materials shared in group are the property of Center for Hope WNY and may not be duplicated or shared without consent.
How did you hear about Center for Hope WNY? *
Social Media
Friend
Website
Radio
Word of Mouth
When would you prefer to participate?
Fall
Winter
Spring
Summer
Please indicate how you wish to participate in this group: *
In person (Buffalo)
In person (East Aurora)
Virtual
No preference
Please indicate your preference for group:
Single gender
Mixed gender
No preference
Submit
