Empower Peer Support Group

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Empower Members are invited to gather together once a month to provide informal support to one another.

Peer support is when people use their own experiences to help each other. There are different types of peer support, but they all aim to: bring together people with shared experiences to support each other. Empower will provide a space where you feel accepted and understood while treating everyone's experiences as being equally important.

What is your name?

What is your phone number? (We will only contact you via phone in the event of a cancellation due to weather)
*Please skip this question if you do not use a phone

Please provide your email address. (We will use this to reach out to confirm the members who will get to attend due to limited space.)

*Please skip this question if you do not use email

Will you be bringing a support person with you?

Yes

Clear selection

Do you require ASL interpretation?

Yes

Clear selection

Do you use a mobility device?

Yes

Clear selection

Are there other accommodations that you need for this activity?

We will be providing some snacks for this activity. Is there anything we should know about your dietary needs or restrictions?

In person space is limited at Empower, and it is possible that we will have more people interested in attending than can fit. We will be taking people who fill out this form on a first come first serve basis. You will be contacted prior to the event to confirm your spot.

Due to limited availability and occasional difficulty when booking Go Bus paratransit, we suggest that you should book your transportation in anticipation of being selected.

Do you understand?

Yes

Clear selection

Individuals who are arranging transportation with Go Bus Transit should book their arrival pickup for no earlier than 6pm, and their return pickup for no later than 8pm.

I have booked my transportation for the suggested time-frame

I was unable to book transportation within the suggested time-frame

This is not applicable to me

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Peer support group is here to help provide support and kindness when you are experiencing something difficult in your life. Is there something that you are experiencing currently that you would like the group to support you with this Month?

Peer support group would also like to help you to celebrate the positive things that are happening in your life. Is there anything that you would like for group to celebrate with you this month?

Members will often share very personal information during Peer Support. All information that is shared throughout this program is intended to be kept private and confidential.

Members who are found to be sharing other members personal information or experiences will be asked to leave the group.

Do you understand and agree to respect individual confidentiality?

I agree to respect this policy.

I may struggle with this policy and would like to discuss it further.

Clear selection

Members may share experiences that make other members feel sad or angry. If you are having negative thoughts or feelings because of something that was shared during this group, it's important that you let one of the staff members know. They can provide support and resources to help you feel better.

I understand, and will let staff know if I am having negative feelings.

I would like for Sherri to check in with me the day after to make sure I'm ok.

Clear selection

Thank you for taking the time to complete this registration form.

Before hitting submit, do you have other comment, question, or concern?

Submit

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