Resource & Referral Program @ EWC - Support Group Update Form

Thank you very much for submitting information about your Support Group!

With your help we can keep providing the western Massachusetts community with up-to-date information about the resources available in our community. If you have any questions, please Contact us. Once we receive your updated information, we will contact you to confirm the information submitted.

This form is also available in pdf format.

GENERAL INFORMATION

Sponsoring Agency:
Agency Phone:
Agency Fax:
Agency Email:
Agency WWW-Site:

Mailing Address:	Physical Address:

SUPPORT GROUP INFORMATION

Title of Group:
Description:
Eligibility:
Location:

Date of First Meeting:		Date of Last Meeting:
Day of Week:		Day of Week:
Time:		Time:
Size of Group:

How often do you start new groups?

IS THE SUPPORT GROUP
Free?	Yes	No
Ongoing/Permanent?	Yes	No
Drop-In?	Yes	No
One-Time?	Yes	No
Open after First Meeting?	Yes	No
Registration Required?	Yes	No
Screening Interview Required?	Yes	No
Wheelchair accessible?	Yes	No
Child Care?	Yes	No
Accessible by Public Transportation?	Yes	No

Fees:
Sliding Scale:
Insurance:
Deferred Payment:
Deadline for Registration:

ADDITIONAL INFORMATION ABOUT THE SUPPORT GROUP

Please enter the characters in the image below:

Thank you very much for providing this information.
Please click the button to your support group information.