Support Group Form

Name of Group *

Approximate number of active group members? *

Please select the organization that this group is affiliated with *

If you answered other, please list the name of the organization.

Is your group a registered non-profit in your state/province/country? *

Is your group incorporated? Examples- LLC, Corporation, LP? (will not be posted on website) *

Email address for public contact (example info@groupname.com) *

Address #1 *

Address #2 *

City *

State/Province *

Zip Code/Postal Code *

Country *

Website

Facebook URL

Twitter Name

Instagram Name

Other Social Media #1 (name of tool and handle)

Other Social Media #2 (name of tool and handle)

Primary Contact First Name (Will be listed on website) *

Primary Contact Last Name (Will be listed on website) *

Primary Contact Email Address (will not be listed on website) *

Please select the option that best identifies your position in the organization

If you listed other, please list it here

First Name of Group Advisor ( A Medical or mental health professional---will not be listed on website)

Last Name of Group Advisor (A Medical or mental health professional---will not be listed on website)

Education of advisor

If you selected other, please list here.

E-Mail Address of Group Advisor (will not be published on website)

Country Code (USA is +1) *

Area Code *

Phone Number (will not be listed on website) *

3 + 0 = ?Please prove that you are human by solving the equation *