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Diabetes Self-Management Support Program

Intake Form

Get support to manage your type 2 diabetes!

Grab a friend or family member and join [Organization]’s Diabetes Self-Management Support Program now. Participating in one of our support groups will give you a trained Lifestyle Coach, along with the tools, information, and guidance you need to live your best life while managing type 2 diabetes.

Would you like to stay in touch with us?

Submit your contact information on the next page to get information about our programs and services.

Name

First Name *
Last Name *

Email

Email *

Tell Us More About Yourself

Overall Instructions: Please read the questions completely before answering. All information provided is confidential.

Address

City
State/Province
Postal/Zip Code

Phone Number

Phone

Date of Birth

Birthday

How would you best describe yourself? *

Other:

What is the highest grade you completed in school?

Are you employed?

YesNoRetired

What year were you diagnosed with type 2 diabetes?

During the past year, have you participated in an educational program about diabetes?

YesNo

How did you hear about this program?

Other:

Class Days and Times

Please indicate which days and times work best for your schedule, keeping in mind that the program will meet weekly for 10 weeks. We will make every effort to accommodate your preference. You will receive an email confirmation regarding your class. Please be aware that all dates and times are subject to change.

Choose your class preference:

11/12/24 10:00 AM CT In-Person11/12/24 1:00 PM CT Online1/14/25 10:00 AM CT In-Person1/14/25 1:00 PM CT OnlineThese dates don’t work for me. Please contact me about future classes

THANK YOU!

By clicking submit, you agree to receive information from [Organization].

Click the submit button below to complete your submission.