Listening Session Registration

Thank you for your willingness to open up and share your story.
Please fill-up this form so we can assist you and send you the Zoom Link to our Listening
Session.
Thank you and keep going, brave one.

leoncioediolata@gmail.com Switch account

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Email *

Record leoncioediolata@gmail.com as the email to be included with my response

You are Welcome to join our Online Listening Session! *

Yes

No

Name *

Your answer
Age *

Your answer

Gender *

Your answer

Contact number *

Your answer

What bothers you lately? *

Your answer

What would you like to share in our listening session? *

Your answer

For emergency, name of the contact person and relationship with him/her *

Your answer
For emergency, contact number of the contact person *

Your answer

What type of listening session you would like to attend? *

One-on-one Listening Session

Group-Listening-Session

In-person Listening Session every 2nd and Last Saturday of the Month 3:00-5:00 PM
at E-merge Space, 5th Floor, Hollywood Square Building, West Avenue, Quezon City
In-person Meet-up and Listening Session this coming September 9, 2023 at 1:00
PM in Quezon City
 Which date are you available to join? *

September 9, 2023 Saturday In-person Meet up (Hybrid with online on zoom) at 3:00-
5:00 pm

September 9, 2023 Saturday 7:00-9:00 pm online via Zoom

September 16, 2023 Saturday 7:00-9:00 pm online via Zoom

September 23, 2023 Saturday 7:00-9:00 pm online via Zoom

September 30, 2023 Free Suicide First Aider In-person (hybrid with online via Zoom)
Training with E-certificate at E-merge Space 1:00-3:00 PM and Listening Session at
3-5PM

September 30, 2023 Saturday 7:00-9:00 pm online via Zoom

A copy of your responses will be emailed to leoncioediolata@gmail.com.

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