Hampshire County Support Group Information Form
*Please refer to the database
Inclusion/Exclusion Criteria
to determine eligibility
                     Submission:
Select..
New Support Group
Update Existing Listing
* Sponsoring Agency Name
Contact Person Name:
Phone
Fax
Mailing Address:
Line 1
Line 2
City:
State:
Zip:
Physical Address:
Line 1
Line 2
City:
State:
Zip:
Website:
Email:
Issues to be addressed:
Eligibility:
Location:
Date of First Meeting:
Date of Last Meeting:
Days of Week:
Mon 
Tue  
Wed 
Thur 
Fri 
Time of Group:
How often do you start a new group?:
Is the Group ( check all that apply ):
Ongoing 
Drop-in 
One-time  
Is the Group open after first meeting:
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Yes
No
Fees:
Select..
Free
Sliding scale
Paid
Amount:
Registration required?
Select..
Yes
No
Screening interview required?
Select..
Yes
No
Deadline Date:
Childcare provided:
Select..
Yes
No
Wheelchair accessibility:
Select..
Yes
No
Accessible by public transport?
Select..
Yes
No
Additional Information:
"We reserve the right to edit information for brevity, clarity, format and space requirements. Inclusion of an agency or organization does not imply endorsement by Center for Women & Community, exclusion does not signify disapproval."