Support Group Pre-Screening & Registration Questionnaire

Support Group Pre-Screening & Registration Questionnaire

She Rested, Then Rose – A Mental Wellness Group for Black Women Entrepreneurs
🖤Welcome, Sis.

So glad you’re here.She Rested, Then Rose is a healing-centered therapy support group created by and for Black women entrepreneurs who are holding so much, giving so much, and ready to reclaim space to breathe, feel, and heal.This space is about more than business—it’s about you. The whole you. Beyond the hustle.We honor the courage it takes to show up for yourself in this way.Please take a few moments to complete this form. Your answers will help us make sure this group is the right fit for your healing goals. All responses are kept confidential and reviewed only by the facilitator(s).
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 information and your client portal will be set up.

This group is not a good fit if you are in a state of crisis, have been diagnosed with moderate to severe depression, have a mood disorder or personality disorder diagnosis, or if you have an ongoing, untreated mental challenge or illness that is not being treated by an individual licensed professional.
How did you hear about this group?*
Legal Name*

First NameLast Name
Preferred Name (if different)
Pronouns*

She/HerThey/ThemOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Age*

21-2425 - 2930 - 3536 - 4041-4546-5051-55Other
I prefer to be contacted? (Check all that apply)*

TextCall/VoicemailEmailText & Call/VoicemailText, Voicemail, & Email
Are you a licensed therapist or wellness provider?*

YesNo
Do you identify as a Black?*

YesNo
Do you identify as a woman (inclusive of trans, cis, queer, and nonbinary femmes)?*

YesNo
I understand that this group is for black women. (Please stop here if you are not a black women and reach out to see if we have another group that can accommodate you.)*
Have you ever participated in a therapy or support group before?*

YesNo
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 severe depression, mood disorder, PTSD, or a personality disorder that requires ongoing, individual treatment?*

YesNo
Are you currently a business owner or entrepreneur?*

Yes – Full-timeYes – Part-time or side businessNot currently, but I have beenPlanning to launch a business within the next 6 months
How long have you been in business or developing your venture?*

Less than 1 year1–3 years3–5 years5-9 years10+ years
What are you hoping to gain from this group? (Check all that apply)*

Support in managing stress, burnout, or anxietyTools to build a more sustainable relationship with workCulturally safe space to share and healReconnecting with joy, rest, and identity beyond businessCommunity with other Black women entrepreneursAccountability for integrating wellness into my business life
On a scale of 1–5, how often do you prioritize your mental/emotional wellbeing in your business journey?

1 – Rarely23 – Sometimes45 – Regularly
This group is built for Black women entrepreneurs who are:

✔️ Open to self-reflection and healing
✔️ Respectful of community care and diverse lived experiences
✔️ Committed to showing up for themselves and others
✔️Not currently in an acute mental health crisis
Does this describe you at this time?*

YesNoUnsure
Are you able to commit to 6 weekly 90-minute group sessions?*

YesNo
What is the name of your company?
Please provide your company website?
What are your company social media handles?
What feels heavy right now in your life or business?*
What helps you feel grounded when you’re overwhelmed?*
What do you hope to feel or experience differently after completing this group?*
Do you have any concerns about sharing in a group setting?*
Is there anything that might get in the way of your participation (time, tech, emotional readiness)?*
Is there anything you may need to feel emotionally safe in a group space?*
Is there anything else you’d like the facilitator to know?*
I understand that this group is therapeutic in nature, but not a replacement for individual mental health treatment. I agree to honor confidentiality, respect, and mutual care within the space.*

I acknowledge
Signature*

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Support Group Pre-Screening & Registration Questionnaire

🖤Welcome, Sis.