A- A A+

Greater Lafayette Online Support Groups -- Information Signup

Information gathering for online support groups

  Personal Information

*

Name:

 

 

   

*

 

 

City/State/ZIP:

 

    

 

*

Date of Birth:

 

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


*


*
Question - Required - I am interested in attending the following Support Groups:
Please make between 1 and 2 selections from the choices below.

*  
Visually impaired? Click here to have an audio challenge played.  You will then need to enter the code that is spelled out.
Change image
CAPTCHA image

*

(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.

 

 

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 Leah Giorgini, Senior Director at: lgiorgini@ywcalafayette.org.

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

 

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

*
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.

*
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.

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

*
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.

   Please leave this field empty