Welcome--this is a space just for you.
Take a few minutes to share what’s on your heart. Your responses help me create a group experience where you’ll feel seen, supported, and safe.
Personal Information
Name
First Name
Last Name
Preferred Name
First Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Group Selection
Which group are you interested in joining?
The Ease Collective - 10 week - Anxiety process group
Eternal Essence - 10 week - Grief Circle
Sacred Thread - 10 week - Process Group
What loss(es) are you currently navigating?
What feels hardest about grief right now?
Have you ever participated in grief counseling or groups before?
Please Select
Yes
No
If Yes: Please share your experience.
What situations or thoughts tend to trigger your anxiety most?
How does anxiety affect your daily life (work, relationships, health)?
Have you ever been diagnosed with an anxiety disorder
Please Select
yes
no
What made you interested in joining a process group?
What would you most like to explore about yourself in community?
What group experiences have you had in the past, if any?
Are you currently in individual therapy?
Please Select
Yes
No
Looking for therapist
If Yes: Name of therapist
Are you currently taking any medications for mental health?
Yes
No
Do you have any current safety concerns (suicidal thoughts, self-harm, harm to others)?
Yes
No
Commitment & Consent
Can you commit to attending all sessions for the group you selected?
Yes
No
Do you agree to uphold confidentiality for all group members?
Yes
No
Is there anything else you’d like me to know to best support you?
Group Meeting Availability Survey
What days of the week generally work best for you to meet?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day usually works best for you?
Morning (9am–12pm)
Midday (12pm–3pm)
Afternoon (3pm–6pm)
Evening (6pm–8pm)
Are you open to weekend sessions if needed?
Yes
No
Maybe
Is there anything else about your availability I should know?
Submit
Should be Empty: