Breaking The Cycle Application

Breaking the Cycle is a sacred space for Black women ready to do the inner work—no shortcuts, no fluff. This application helps us ensure each group member is aligned with the purpose, energy, and commitment needed for this journey. We're not looking for perfection—we’re looking for presence, willingness, and honesty. Please take your time. We’re rooting for your healing.

Name

First Name

Last Name

Phone

(###)

###

####

How did you hear about Black Girls Can Heal and this support group?

What cycle are you currently working to break in your life?

(Examples: unhealthy relationships, self-sabotage, people-pleasing, generational trauma, spiritual disconnection, etc.)

Why do you feel now is the right time for you to begin (or continue) this work?

What does commitment to healing look like for you right now?

(Check all that apply)

I’m willing to show up consistently, even when it’s uncomfortable.

I’m open to being challenged in love.

I can set aside time weekly for reflection, journaling, or assignments.

I understand this is not therapy, but a peer-led support space.

I’m just curious, not ready to dive deep. (Note: This group may not be a good fit if checked alone.)

What are you hoping to receive from this group experience?

Are there any accessibility needs, time zone issues, or concerns you'd like us to know about?

(Optional)

This group requires active participation for 6 weeks. Are you prepared to commit to attending all sessions unless there is an emergency?

Group Guidelines: (a) Confidentiality: What is shared in the group stays within the group. Respect each member's privacy; (b) Active Participation: Engage actively in discussions and activities. Your presence matters; ( c) Respectful Communication: Be mindful of your language and tone. Respect diverse opinions and experiences; (d) Empathy and Support: Offer empathy and support to fellow members. We are here to uplift each other. (e) Timeliness: Be punctual for meetings to benefit fully from the session. By signing below, the participant agrees to abide by the Black Girls Can Heal Support Group Agreement and commit to fostering a safe and supportive environment for all members. (my selection 'agree' serves as my electronic signature).