SuperMom Support Registration

SuperMom is a Collaboration of LCL MA and WBA Parents' Forum

Only fields marked with an asterisk(*) are required. Please complete this entire form if you haven't provided the information to us already on a previous signup form. If you've completed an intake before, please just update any new information you might have to keep our records current.

Skip any questions that are not relevant to you. Information submitted is secure and confidential.

Contact Information

First Name

Last Name

Nickname?

Pronouns

If other pronouns, please provide

Email Address

Mobile Phone

Home Address City

Home Address State

Home Address Zip

County

Demographic Info

Responses are NOT required. We ask for the information below for statistical purposes and to measure our organization's reach. We keep all information confidential and secure.

Sex

If other sex, option to specify:

Birthdate

Required format: MM/DD/YYYY

Race & Ethnicity (You can select multiple.)

If other race/ethnicity, option to specify:

Do any of the following LGBTQ+ categories apply to you? (You can select multiple.)

If other LGBTQ+ category, option to specify:

Have you been diagnosed with a disability or do you identify as having a disability?

YesNoPrefer Not to Answer

Optional space to specify the disability or disabilities:

Marital Status

Bar Admission Status

Law School

Graduation Year

Employer Type

NOT a lawyer?

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If other, please specify:

Name of individual referral source, if desired:

LCL Staff will use email to communicate with you about matters such as scheduling, referrals, information about services (including new offerings), and for follow-ups to check on how things are going. Check below if you'd prefer NOT to be contacted following your last scheduled LCL session.

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Addiction Recovery Listserv. LCL maintains an email listserve for lawyers in recovery. To be added, please provide your preferred email address:

By submitting this form, you agree that you have read and understand the LCL "Information for New Clients", available via this link. You also understand that if you are referred to an outside provider, LCL will disclose relevant info to the provider.

If you have any questions or concerns, please email rachel@lclma.org.

Contact Information

Bar Association	Board of Bar Examiners
Board of Bar Overseers	Client
Colleague, Friend, or Family	CPCS
Employer	Exhibitor Table at Event
Internet Search	Judge/Judiciary
Law School	LCL \| Mass LOMAP Staff
Mass Lawyers Weekly	Other:
Practicing with Professionalism	Presentation by LCL \| Mass LOMAP Staff
Print Advertisement	Read Article by LCL \| Mass LOMAP Staff
Recovery Meeting	SJC Standing Committee on Lawyer Well-Being
Social Media	Treatment Provider
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