Support Group for Black Men

This group is to explore the experiences and identity of being a Black man in various spaces. You may be feeling stressed or anxious and find that friends, family, or close acquaintances just don’t understand. This group is for men that need support but are not in traumatic situations or currently in crisis. You may be seeking support for daily stressors from your life, relationships, society, or work. It's a good fit if you are overwhelmed with the impacts school, parenting, peers and romantic relationships or the intense racial climate. This group is not a good fit if you are in a state of crisis, bring or exhibit inappropriate behavior to the group, or if you have an ongoing, untreated mental challenge or illness that is not being treated by an individual licensed professional.

NOTE: This is a new group that is actively being filled. Once the minimum number is reached, all accepted participants who responded will be emailed with further info and your client portal will be set up. To learn more about the group please check the group page: I Choose Healing | Support Group for Black Men

Name*

First NameLast Name

E-mail*

example@example.com

Phone Number

I understand that this group is for black men. (Please stop here if you are not a black man and reach out to see if we have another group that can accommodate you.)*

YesNo

Have you ever participated in a support group before? If yes, what was that experience like? Was there anything in your previous you were concerned about?*

Do you feel comfortable sharing and listening to others in a group setting? This is important as you will be apart of an online support group.*

YesNo

Are you currently seeing a therapist or counselor?*

YesNo

Have you been diagnosed with any mental health conditions that require ongoing, individual treatment (e.g., severe depression, PTSD, or a personality disorder)?*

YesNo

Have you experienced any recent mental health crises (e.g., hospitalizations, suicidal thoughts) that might require more focused individual care?*

YesNo

I understand this group is offered weekly and online. I am willing to make the required 10 week minimum commitment to attend the group.*

Yes, I understandNo, I can't make the minimun commitment

I understand the rate for this group is $95 per session.*

YesNo

I understand that this group is a support group that is not covered by insurance and I will have to pay out of pocket. I understand I can use my HSA/FSA funds and any debit or credit card.*

YesNo

Are you able to commit to maintaining confidentiality and respecting the boundaries of others in the group? (This is critical in maintaining trust, connection, and rapport in the group.)*

YesNo

Are you available to attend group sessions at the scheduled time, Wednesdays @ 2p)?*

YesNo

Do you or will you have access to a private and quiet space with a stable internet connection for online sessions? (You can participate where it is convenient for you as long as you have privacy, not in a moving vehicle, and can help maintain your confidentiality and others in the group.)*

YesNo

I understand that I am signing up for this group and I'm ready to move forward and get started on my healing journey?

YesNo

Date of Signature*

Date

Signature: (By signing this form I understand that I am being considered for group enrollment and that once accepted I still need to complete all paperwork to gain access to the group.) *

Please leave any questions, suggestions, or concerns.