Interest Form For Groups and Classes
Fill out the below questionnaire and we will notify you when we have a group or class available that meets your needs.
DateTime
WE CURRENTLY DO NOT HAVE ANY ACTIVE GROUP RUNNING. PLEASE COMPLETE THIS FORM AND WE WILL CONTACT YOU IF WE BEGIN A GROUP THAT MEETS YOUR NEEDS.
Are you looking to attend group therapy or to attend a class?
Group Therapy
Class
What type of group therapy are you looking for?
*
Depression Group
Grief Group
Anxiety Group
Anger Management Group
Addictions Group
Substance Abuse Group
Co-Dependency Group
Suggest a group you would like to see in the future
What group would you like to see in the future?
What class do you have interest in when available?
*
Couples Communication Class
Suggest a class you would like to see in the future
What class would you like to see in the future?
Gender of person seeking group therapy
Male
Female
Other
If age specific groups are available, please mark any age specific groups/classes you are looking for.
Ages 4-6
Ages 7-12
Ages 13-17
Ages 18-24
Ages 25-64
Ages 65+
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Schedule
Help us know any times you would be able to attend a group or a class.
Select ALL days/times you could make work with your schedule.
*
I am flexible and can make anything work
Mon mornings 10 am-12 pm
Mon afternoons 1 pm-4 pm
Mon evenings 5 pm-8 pm
Tues mornings 8am-12 pm
Tues afternoons 1 pm-4 pm
Tues evenings 5 pm-8 pm
Wed mornings 8 am-12 pm
Wed afternoons 1pm-4pm
Wed evenings 5 pm-8 pm
Thur mornings 10:30 am-12 pm
Thur afternoons 1 pm - 4 pm
Thur evenings 5 pm - 8 pm
Fri mornings 8 am - 12 pm
Fri afternoons 1 pm - 4 pm
Fri evenings 5 pm
Sat morning 8 am-12 pm
Sat afternoon 1 pm - 4 pm
How did you hear about us?
*
Be Specific, for instance, if a friend referred you, please provide name of referring friend
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Contact Information
We will notify you as soon as a class or group is available.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: