4 Week Group Therapy Course

1

2

3

Name

First Name

Last Name

4

What are your preferred pronouns?she/her, he/him, ze/zir, they/them

5

Please provide your email

example@example.com

6

Are you currently in therapy or have you had therapy/coaching/counseling in the past?This group is open to people that have had therapy and to those that haven't.

Yes, I am currently in therapy

I am not currently in therapy, but I have had therapy before

No, I have never had therapy

Other

8

What do you hope to get out of this 4-week group therapy experience?

9

Do you have questions, concerns or anything you would like to share?

10

I understand this group will be confidential, all information shared in this group is expected to stay within the group and not made public in any way.

YESNO

11

This course is not appropriate for you in the following instances: If serious violence or threats of violence occur in a relationship you are in; if you are currently experiencing suicidal or homicidal thoughts,If you currently have a major untreated illness,If there is active severe alcohol and/or drug addiction. Do any of these instances apply to you?

YESNO

12

I commit to the total payment of €260 and 4-weeks of participation to the best of my ability. I am paying via...Further terms & condition are included in the consent form and will be sent to you via email after completing this form.

One Installment of €260

Two Installments of €130

Other Payment Option Needed