Initial Form
Thank you for reaching out about the Motherless Daughters Support Group, led by Lea Schupak, LMHC, PMH-C.
Please fill out the form below related to the next Group series, which will be starting soon.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
City and State that you currently reside in
Are you currently in therapy? (If so, please state whether it is individual, couples, family, group, etc and how long you have been in therapy for.)
Have you ever attended any type of group therapy before? (If so, please specify what it was for and whether you found it helpful or not.)
This group is for women who have lost their mothers. Please share with Lea Schupak, LMHC the following information: how old you were when you lost your mother; how old you are now; the cause of death.
Please provide any other information you feel the group facilitator should know about you, your loss, or your mother.
Would you prefer to meet virtually, or in person? (If in person: the office is located on the Upper West Side of Manhattan, NYC.)
Virtually
In person
Does not matter to me, both options could work
Please specify your preference with regards to the time:
Monday evenings from 6 pm until 7:15 pm
Monday evenings from 6:30 pm until 7:45 pm
Wednesdays from 1 pm until 2:15 pm (virtual only)
None of these work for me
Motherless Daughters groups are typically "closed" groups, meaning that it is the same members meeting every week, with the members agreeing to a specific time commitment. They are not "drop in" groups. This is done to ensure an intimate environment, where true connections can be formed. Therefore, if you choose to sign up, you are asked to commit to the group before it begins, and do your best to attend as many group sessions as possible. Please write your initials below to indicate that you understand and agree to this.
Of course, if any issues arise and you are not satisfied with the group, you will be offered a partial refund. All refunds are subject to a $25 admin fee. No refunds can be offered after the first two meetings. You are always welcome to voice your concerns to the group facilitator, who will do her best to assist you and promote a positive experience for you.
You may be eligible for partial insurance reimbursement for the fee you pay to attend this group. Lea Schupak, LMHC cannot guarantee how your insurance will process your claim, but she can provide you with a receipt to show your insurance company.
Yes, I am interested in submitting this to my insurance company to see if I may be eligible for reimbursement, and will therefore need a receipt to be provided to me by Lea Schupak, LMHC.
No, I am not interested in submitting for potential reimbursement.
I don't understand this and could use more information on what this means.
Please note: this form uses an encryption technology for the security of your data.
Submit
Thank you for completing this form.
Lea Schupak, LMHC, PMH-C will be in touch with you shortly to schedule a short video consultation to ensure fit and answer any questions you may have. Looking forward to connecting with you soon!
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