Group Interest Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you a current Clintonville Counseling and Wellness client?

YesNo

Who is your clinician?

Emergency Contact Name

First NameLast Name

Group(s) I am interested in:

Trans and Gender Expansive “Stitch and Bitch” Social Group (2 hours)Visual Journaling (90 minutes)Therapeutic Dungeons & Dragons (90 minutes)Identifying and Processing Rage for BIPoC (90 minutes)Embracing Awkward: A Social Skills Group (2 hours)

Groups at Clintonville Counseling & Wellness operate on a pay-what-you-can model. We suggest $10-50 per group for 60 minute groups, $15-75 per group for 90 minute groups, and $20-$100 per group for 2 hour groups. However, we want groups to be accessible for all so we will not turn anyone away for not being able to pay our sliding fee scale. (Please note: our Trans and Gender Expansive “Stitch and Bitch” Social Group is always free to participants.)

How much are you able to commit per group?