SuperMom Support Registration

SuperMom is a Collaboration of LCL | Mass LOMAP 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

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Email Address

Mobile Phone

Home Address City

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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

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Birthdate

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

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

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Optional space to specify the disability or disabilities:

Marital Status

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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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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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