Survey - Greater Lafayette Online Support Groups -- Information Signup

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Greater Lafayette Online Support Groups -- Information Signup

Information gathering for online support groups

Personal Information

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Name:

First Required	Last Required

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Email: Required

Street Address:

City/State/ZIP:

City	State	ZIP

Phone Number:

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Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from YWCA.

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Question - Required - Please select your county of residence:

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Question - Required - I am interested in attending the following Support Groups:
Please make between 1 and 3 selections from the choices below.

	Empower!
	Expressions
	Love & Logic

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Question - Required - Please record the following text:

Change image

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Question - Required - Please enter a safe contact method for us to reach you. You may supply an email, telephone number to text, or telephone number to call. Links, joining instructions, and information about cancellations or changes will be sent here.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Optional: I identify as a survivor of:
Please make up to 3 selections from the choices below.

	Domestic Violence
	Sexual Assault
	Other Trauma

Online Support Group Waiver

During COVID-19 and its aftermath, social distancing measures have made in-person support groups more challenging. YWCA Greater Lafayette is utilizing online video support groups as a critical tool to help survivors. Please read the important privacy information below. If you have questions or need clarification, please email Meghann Dubea, Director at: mdubea@ywcalafayette.org

By joining our online support groups you indicate you agree to the following items:

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Question - Required - Those video groups will NEVER BE RECORDED OR CAPTURED, and will be considered confidential facilitator-participant product.

I acknowledge this.

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Question - Required - While we at YWCA Greater Lafayette can make every effort to secure all of our client communications, the various video platforms available have had some challenges which are beyond our control.

I acknowledge and understand of these tools.

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Question - Required - The information shared in a domestic violence counseling group must be treated with the deepest respect. State and federal Law mandates that any survivor's personally identifying information is the exclusive possession of that survivor and may not be shared, with few exceptions, without that person's written release of information. What is heard in group stays in group.

I acknowledge that the information shared in this group session is strictly and legally protected.

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Question - Required - To best support and assist you we will need to access and review your information within our offices and personnel only.

I consent to YWCA's receipt of my protected information for this purpose only.

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Question - Required - Under State and Federal Law, YWCA Greater Lafayette MUST keep your personally identifying information PRIVATE, and will not disclose that information unless compelled by law, a court order, or your specific permission.

I acknowledge and understand this.

Spam Control Text: Please leave this field empty

605 N. 6th Street Lafayette, IN 47901 | Phone: (765) 742-0075 | communications@ywcalafayette.org

Privacy Policy