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At the Global Woman Center we regard inquiries and counseling discussions as private and confidential. Any information provided will be treated in confidence. No information of any kind is given to anyone outside of the Center unless specifically requested in writing, although in rare circumstances we reserve the right to widen confidentiality if there appears to be a serious risk of harm. Please complete this form and return to us prior to setting up your appointment. You may also call to request this form. Return completed form to Global Woman Center, 14001A Grumble Jones Court, Centreville, VA. 20121.
  • Questionaire

  • Please note: Our first appointment for one-on-one is at 10:00am and our last appointment for one-on-one is at 11:00am, only on Wednesdays & Saturdays. One-on-one appointments last for no more than an hour and no less than 30 minutes.
  • If you checked “Yes”, specify the day & time slot you prefer for your appointment:
  • If you checked “No”, you will be included in the Round Circle Discussion. By providing your email address and phone number, you will be sent an invitation to join us in the Round Circle Discussion, which is held once a month. You will be required to respond to the invitation to reserve your seat at the Discussion.
  • If yes, how many do you have?
  • If yes, what are their ages?
  • If “Yes”, please indicate how long ago or is it current.
  • Approximately what year was FGM performed on you?
  • Please note: Reconstructive surgery will reverse what FGM did to your vagina. This surgery will be performed by well-trained and experienced OB/GYNs. The cost of this surgery is at least $1700 but by being a client of the Global Woman Center and attending your appointments and the Round Circle Discussion, you could become eligible for assistance with the surgery.
  • Please note: The services at the Global Woman Center are at no cost to our clients. However the cost of the surgery must be paid to the OB/GYN. The Global Woman Center raises funds to support the cost of the surgery for our clients. Our Center will negotiate with insurance companies for possible coverage in whole or in part on behalf of our clients. However the Center is committed to assisting our clients in obtaining the surgery and physical therapy.
  • Referral