Pieces of Peace signup : Community Support Services : Get Help : Tubman

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First Name *

Last Name *

Current address

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Phone number

If Tubman needs to call you, is it safe to leave a message?

Is it safe for Tubman to email you a link to the group meeting?

Do you have a safety plan?

Is it safe for Tubman to email you safety planning information?

How were you referred to Pieces of Peace?

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What do you hope to receive from attending a support group?

Are there any topics you would like covered in the group?

I understand that all information shared within this support group is confidential, and I agree to keep that confidentiality for all participants.

Please check box to indicate your agreement.

The following demographics questions are for Tubman's data collection purposes. All answers will remain confidential.

Date of Birth

Month

Day

Year

Gender

Primary Language

Which ethnicity best describes you?

Which race best describes you? (You may select multiple options.)

Do you have any of the following conditions or disabilities (You may choose as many as apply)?

Any special accomodations needed?

Thank you for signing up for Pieces of Peace. You will receive an email soon with more information about joining the virtual group.

If you need any assistance, please call Tubman's 24-hour resource and crisis line at 612.825.0000.

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