First Time Visitors Form

  • Your data is kept confidential at Hope Connections. Your information will never be sold or shared with a third party.
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  • Personal & Contact Information

  • About

    Please complete the following for yourself or for the person you are here to support.
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  • The next two questions are optional. This information will be kept confidential and not shared with your employer and will be aggregated for grant purposes only.
  • Special resources are available for those with household incomes below $25K
  • Additional Information

    Please note: Attendance at an orientation is required before attending Support Groups and Mind/Body classes. Unless otherwise noted, all of our programming are for those age 18 and over. Comfortable clothing and physician approval recommended for all exercise Mind/Body Classes.
  • Please write the name of the person who referred you, or n/a if not applicable.
  • Hope Connections reserves the right to refuse to provide services to participants and to allow participants to engage in Hope Connections programs who violate or threaten to violate Hope Connections’ policies, are threatening or disruptive to staff or other participants or who appear to present a potential danger to the participant, staff or other participants.