Adult Registration | Melting Pot Healing

Program Application

Thank you for taking the first step toward healing, growth, and empowerment. Our mission is to provide a supportive environment where women can find encouragement, develop healthy relationships, strengthen parenting skills, and access resources that promote personal and family well-being.

Please complete this application to help us better understand your needs and determine which programs may best support your journey.

Please Fill in N/A for blank answers.

Legal First Name

Legal Last name

Phone number

Are you currently a parent or legal guardian?

Yes

No

If Yes, how many children do you have?

What best describes your current family situation?

What inspired you to seek support or participate in our programs?

We want to understand what brought you to us and how we can best support you.

I certify that the information provided in this application is accurate and complete to the best of my knowledge. I agree to treat fellow participants with dignity, respect, and compassion and to respect their privacy. understand that participant privacy and confidentiality are valued. However, confidentiality cannot be absolutely guaranteed in group settings, and applicable safety and legal reporting obligations may require disclosure.

Full Legal Name

This will be documented as a signature.