Mending the Heart Cohort Application

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Community Counseling Level 1

First name*

Last name*

City*

State/Region*

Country/Region*

Phone number*

Email*

Race &/or Ethnic Identity*

Gender Identity*

Pronouns*

Religious and/or Political Affiliations or Beliefs*

How did you hear about our Mending the Heart Cohort?*

Organizational Affiliation*

Tell us a bit about yourself*

Why are you interested in our Mending the Heart Cohort?*

Have you participated in any Ayni events or programs previously?*

If so, which one and what year?

How would you describe your involvement in social change work? For example, do you volunteer, work or participate in groups dedicated to social change? What’s been your role(s)?*

How many years have you been engaged in social change work?*

If you’re trying to attend with someone else that you know, who are they?

Do you want to attend the in-person or the online Orientation Training or are you open to either? (You must be able to attend one of them) *

If you chose in person (October 4-5), we will be hosting either in upstate NY or in Revere, MA. Can you make it to either locations or only one?*

Are you available to attend the following virtual weekly sessions? (We will only accept participants that can make it to all sessions.)

October 23, 6-9pmEST*

October 30, 6-9pmEST*

November 6, 6-9pmEST*

November 13, 6-9pmEST*

November 20, 6-9pmEST*

November 25, 6-9pmEST*

Depending on the number of Boston participants, we may offer in-person weekly gatherings in Revere. Would you like to attend them if they are offered? (October 23-November 25) (Yes, No, Maybe)*

Any additional comments or questions?