PreScreen & SignUp for Support Groups for Women

Support Groups for Women

This is a pre-screening to see if the group is a good fit and a signup form for any group you may be interested in. Please complete all questions.
This group is to explore the experiences and identity of being a woman in various spaces. You may be feeling stressed or anxious and find that friends, family, or close acquaintances just don’t understand. These groups are for women that need support but are not in traumatic situations or currently in crisis. You may be seeking support for daily stressors from your life, parenting, family, relationships, society, or work. Group support is a good fit if you are ready to discuss, process, and address all that you are overwhelmed with and the impacts it is having on your emotional and mental health while supporting and holding space for others. This group is not a good fit if you are in a state of crisis or if you have an ongoing, untreated mental challenge or illness that is not being treated by an individual licensed professional.
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number
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 experienced any recent mental health crises (e.g., hospitalizations, suicidal thoughts or any kind of ideation ) that might require more focused individual care?*
Have you been diagnosed with any mental health conditions that require ongoing, individual treatment (e.g., severe depression, PTSD, or a personality disorder)?*
Do you (or will you during the group session) 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 the rate for groups is $95 per session.*

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.)*

Yes, I understand and can make the minimum commitmentNo, I can't make the minimum commitment
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 that will be required to remain on file in my client portal.*

YesNo
What group are you interested in? (These are new groups and are being actively filled. Once the minimum number is reached you will be emailed and your client portal will be set up.)*

Coparenting Support Group (Meets Monday or Wednesday @ 12p)Divorce Support Group (Meets Wednesday @ 3p)Mom's Group for Anxiety (Meets Mondays @ 1p)Anxiety & Boundaries Support Group (Meets Mondays @ 1p)Explore and Soar Women's Support Group (Meets Wednesdays @ 12p)BreakUp Group (Meets Tuesdays @ 2p)
Are you ready to move forward and get started with your healing journey with the group of your choice?*

YesNo
Date of Signature*

MonthDayYear
Date
Signature*

Clear
Please leave any questions, suggestions, or concerns.
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