Workshop 1 Application | Center for Hope WNY

The cost for this workshop is $450 per participant. A $75 non-refundable deposit secures your seat and is applied toward the full cost. We cap each session at six (6) participants. Financial assistance is available and the Center for Hope of WNY is committed as helping as many survivors as possible.

Fields marked with an * are required

Are you seeking financial assistance? *

Yes

First Name *

Last Name

Email *

Phone

NOT Safe to call

NOT Safe to text

Gender *

Female

Male

Non-Binary

What are you hoping to learn 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 check off the following statements to indicate your understanding and consent: *

If you did not request financial assistance, the total cost for the 6 sessions is $450. Payment must be made directly to the group facilitator. The group facilitator will discuss payment options with you prior to the start of the first session.

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.

Please sign your signature in the box below (with your finger or mouse)