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Virtual Therapist Led Support Group Signup

Thank you for signing up for our new Therapist Led Infertility Support Group. For grant writing purposes, we do ask for select demographic information, but your are not required to provide this in order to join. This helps us fund our programs and support community members like you.

To view our Privacy Policy click here: https://www.utahinfertilityresourcecenter.org/terms-and-conditions

Contact Information

Name

First Name

Last Name

Verify Email

Phone Number

Address (For grant writing purposes)

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

Country

Is this your first time registering for this support group?

Demographic Information

Please complete the following questions. The responses are used for grant writing purposes only.

Gender

Age

Ethnicity

What is your yearly gross income?

Less than $50,000

$51,000 - $75,000

$75,000 - $99,000

$100,000 or higher

Choose not to answer

What is your current family size?

Please include all members of your household, including yourself.

Choose not to answer

How did you hear about us?

Facebook

Instagram

Google

Friend/Family

Someone who attends our support groups

Radio

Infertility clinic/provider

Would you like to join UIRC's Mailing List

keep up to date on other events and opportunities in the infertility community

Find Our Support Group Rules Here

I have read and agree to follow the UIRC group guidelines. I understand that our group leader is a licensed therapist, but that this group is not a substitution for therapy.

Signature (Please type your full name to sign this form)