Young Adult Group Interest Form

Young Adult Group Interest Form

Please complete the form below, and one of our group facilitators will contact you! If you would like to speak with someone sooner, please give us a call (516-785-0323). Thank you!
This group is specifically designed to be a source of social and therapeutic support for young adults who may be struggling to cope with the stressors of adjusting to adulthood (i.e., relationships, college, work, "adulting," etc).
Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Format: (000) 000-0000.
Are you currently a patient at South Shore Counseling?
If so, who is your therapist?
Insurance name
Insurance Plan Name
I.e., BCBS, NYSHIP, United, etc.
Insurance Policy Number
Insurance Policyholder Name
We are planning a time that works for all group participants. Below, please check off which of the times work for you. If both work, please check both time slots. If neither work, please check off "Neither."
What interests you about joining this group? Check as many as apply to you!
Do you have any additional concerns you'd like to explore in the group?
How would you describe your current emotional well-being?
Have you ever participated in a support group before?
Do you have any accessibility or mobility needs we should be aware of?
If yes, please describe:
Is there anything else you would like us to know?
Should be Empty: