Elder Intake — AFRO Wellness

1. Contact Information

Full Name

Preferred Name

Phone Number

Email

Preferred Way to Be Contacted

2. Community & Cultural Identity

Where do you currently live?

Where have you lived in the North (NWT, Nunavut, Yukon) or elsewhere?

What communities do you feel connected to?

How do you describe your cultural or ethnic background?

Languages you speak or are comfortable using

3. Your Wisdom & Lived Experience

What areas of community life, culture, or wellbeing are you passionate about sharing?

Are there particular topics you feel called to guide us on?

Are there topics you prefer not to speak about?

4. Ways You Would Like to Contribute

Please check all that feel right for you:

Sharing stories or teachings Participating in discussion circles Offering guidance on programs Supporting youth or families Providing cultural knowledge or practices Helping us understand community needs

5. Availability & Comfort

How often would you like to connect with AfroWellness?

Preferred meeting format

Any accessibility needs or accommodations?

6. Final Thoughts

Is there anything else you'd like us to know about you, your journey, or how we can honour your role in this work?

Strengthening Our Circle

Thank You, Elder