BIPOC Ladies Sign Up

creasman counseling, pllc

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Please complete the form if you'd like to join the Ladies' Group. If you have questions, please reach out to Taylen via email.

* Indicates required field

Name *

First

Last

Personal Pronouns *

What is your gender identity? *

Cis Woman Trans Woman Non-binary Person Two-Spirit Other gender Identity

If "Other," how do you identify? *

What is your race? *

Black/African American Biracial/Multiracial Indigenous person Person of Color

My race wasn't listed - I identify as: *

In the last 6 months have you experienced any of the following: *

Thoughts of harming yourself Thoughts of harming others Hospitalization for mental health concerns Inability to leave your home or take care of your basic needs due to mental health concerns None of the above

Email *

Are you 18 years of age or older? *

yes no

Are there other identities that are important for us to know about? *

Including gender, sexuality, disability, etc.

Have you ever participated in individual or group counseling before? *

Individual Group Both Neither

Submit

Creasman Counseling, PLLC

715 West Morgan St.
Raleigh, NC 27603

2009 Chapel Hill Rd.
Durham, NC 27707

790 Cardinal Rd. #6
New Bern, NC 28562

(p) 919 977 0087
(f) 919 890 0852
info@creasman-counseling.com

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Home
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