Section 1

Personal information

Let's start with the basics, so we know who we're talking to and how to reach you.

Full name

Preferred name

Pronouns (optional)

Date of birth

Phone

Email

Preferred contact method

Phone Text Email Other

If other, please specify

Is it safe to leave you a voicemail message?

Yes No

Mailing address

Emergency contact name

Emergency contact phone

Relationship

Section 2

Current situation

What brings you to our program today? Check all that apply — there's no wrong answer.

Other

Section 3

Safety & wellness screening

These questions help us make sure LUMA is the right fit for you right now, and that we can support you well. All responses are confidential and reviewed only by LUMA staff.

Are you currently in a safe living situation?

Yes No Prefer not to answer

Do you feel safe returning home today?

Yes No Prefer not to answer

Are you currently experiencing, or recently leaving, a situation involving domestic violence, abuse, or danger to your safety?

Yes No Prefer not to answer

We want you to know: LUMA provides peer support and community, not crisis intervention. We can help connect you to additional resources, and a member of our team will follow up privately before your Zoom intake interview.

Is the person who harmed you aware that you are seeking help?

Yes No Prefer not to answer

Do you have a current restraining or protective order?

Yes No

Would you like assistance creating a safety plan?

Yes No

Are you currently working with a therapist, counselor, or social worker?

Yes No

Do you currently have other support?Family, friends, therapist, support groups, faith community, attorney, etc.

Are you in a stable enough place to engage in group reflection and community sharing?

Yes Mostly, may need extra support No, need individual support first Other

If other, please specify

Are you currently in an active crisis?

Yes No

If yes, we strongly encourage you to connect with crisis support before joining a cohort. LUMA can help point you to local resources — 988 (Suicide & Crisis Lifeline) is also available 24/7.

Section 4

Current needs

Do you currently need assistance with any of the following?

Other

Section 5

Participation

Which services interest you?

Would you be interested in volunteering after completing the program?

Yes Maybe No

Is there anything else you'd like us to know to better support you?

Section 6

Participation support

This helps us understand what support would make it possible for you to participate fully. All information is confidential.

Do you have children or dependents in your care?

Yes No

If yes, do you need childcare support to attend sessions?

Yes No, arrangement in place Not sure yet

Do you have reliable transportation to attend in-person sessions?

Yes No Not sure yet

Are there any other access needs we should be aware of?

What days and times would work for you?

Weekday mornings Weekday afternoons

Section 7

Background & referral

How did you hear about the LUMA Initiative?

Were you referred by someone? If so, who?

Have you participated in a women's wellness or support program before?

Yes No

If yes, please describe briefly

Section 8

Attendance commitment

The LUMA Initiative cohort is a structured, time-bound program. Consistent attendance is essential — both for your own growth and for the integrity of the group. By checking these boxes, you're committing to:

Attending scheduled sessions consistently Notifying LUMA 24 hrs in advance if I must miss a session Engaging fully and respectfully with the cohort Completing between-session reflections/materials

I understand that missing sessions without prior notice may result in my spot being offered to someone on the waitlist.

Signature (type your full name)

Date

Section 9

Agreement & signature

I confirm that the information I've provided is accurate to the best of my knowledge. I understand that LUMA Initiative is a peer-support and community wellness program, not a clinical or crisis service, and I agree to engage respectfully and commit to the cohort as described.

Signature (type your full name)

Date

Next step: our team will reach out within a few business days to schedule a brief 20–30 minute Zoom intake interview — to get to know you, answer your questions, and confirm your placement in an upcoming cohort.

Almost there

Review your responses

Take a moment to check everything looks right before you send it our way.

Thank you for trusting us with this

Your intake form has been received. Our team will reach out within a few business days at the contact you provided to schedule your Zoom intake interview.

Questions in the meantime? Email hello@lumayogastudio.com