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Grief & Loss Counseling Group - Sign Up Request Form

Name*
First Last
Phone*
Email*
Newsletter Sign Up
- Subscribe me to HELP Center's monthly newsletter & program updates
Address*
Street Address Address Line 2 City State ZIP Code
When was the date of your loss?*
Briefly describe why you want to join this group.*
All information that you provide us will be confidential as required by state and federal law.
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Name
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COVID-19 Anxiety Counseling Group - Sign Up Request Form

Name*
First Last
Phone*
Email*
Newsletter
- Subscribe me to HELP Center's monthly newsletter & program updates
Address*
Street Address Address Line 2 City State ZIP Code
Briefly describe why you want to join this group.*
All information that you provide us will be confidential as required by state and federal law.
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Individual Counseling - Sign Up Request Form

Name*
First Last
Phone*
Email*
We guarantee 100% privacy. Your information will not be shared.
Newsletter
- Subscribe me to HELP Center's monthly newsletter & program updates
Address*
Street Address Address Line 2 City State ZIP Code
Briefly describe why you are seeking counseling.*
All information that you provide us will be confidential as required by state and federal law.
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Transitioning Women's Support Group - Sign Up Request Form

Name*
First Last
Phone*
Email*
Newsletter
- Subscribe me to HELP Center's monthly newsletter & program updates
Address*
Street Address Address Line 2 City State ZIP Code
Briefly describe why you want to join this group.*
All information that you provide us will be confidential as required by state and federal law.
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Condom of the Month Club - Change of Address Request

Name*
First Last
Email
Old Address*
Street Address City State / Province / Region ZIP / Postal Code
New Address*
You must live in the DFW area to be eligible for this program.

Street Address City State ZIP Code
Phone*
All change of address requests will be voice verified.
Comments
This field is for validation purposes and should be left unchanged.

Condom of the Month Club - Cancelation Request

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
All cancelation requests will be voice verified.
Email*
We're sorry to see you go. Please help us improve our service by letting us know why you decided to cancel.*
Your responses will be kept confidential and will not be shared with any other party. Responses will only be used to help improve HELP's free Condom of the Month Club service.
Cancelation Reason - Other*
Please describe your reason.
Name
This field is for validation purposes and should be left unchanged.

Join the Condom of the Month Club!

Condom of the Month Application

Name*
First Last
Address*
*You must live in the state of Texas in the DFW area to be eligible for this program.

Street Address Address Line 2 City State: Texas Only ZIP Code
Phone*
All online applications will be voice verified.
Email*
We guarantee 100% privacy. Your information will not be shared.
Email Newsletter Opt-in
- Subscribe me to HELP Center's monthly newsletter & program updates
Ethnicity*
Other Ethnicity*
Gender*
Other Gender*
Sexual Orientation*
Other Reason*
Age*
Birthday
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DD
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Consent
I agree to the privacy policy.
Phone
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Grief & Loss Counseling Group - Sign Up Request Form

COVID-19 Anxiety Counseling Group - Sign Up Request Form

Individual Counseling - Sign Up Request Form

Transitioning Women's Support Group - Sign Up Request Form

Condom of the Month Application

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FILTER BY

Atlas® Black Condom

Atlas® Colors Condom

Atlas® Extra Large Condom

Atlas® Non-Lubricated Condom

Atlas® Studded Condom

Atlas® Ultra-Lubed Condom

b Condoms Classic Ultra-Lubricated

b Condoms Extra Strength

b Condoms Studded

b Condoms Tropical Colors – Green

b Condoms Ultra Sensitive

Caution Wear Grande Lubricated Condoms

Caution Wear Iron Grip Snugger Fit Condoms

Crown Lubricated Condoms

ID Extra Large Lubricated Condom

ID Extra Thin Lubricated Condoms

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