Introduction to Mindfulness Group Interest Form
Thank you for your interest in our six week mindfulness group! We will be running our group on Thursday evenings from 5:30-7:00 starting February 5, 2026. Read below for more information about this group and complete the form below to indicate your interest in this group. Completing this form does not guarantee a spot in this group. After you complete the form, we will contact you within one week** to schedule a consultation call and make sure this is a good fit for you.This form will close at midnight on January 23rd. Please reach out if you have any questions!**If you complete this survey between 12/24 and 1/2, we will contact you after 1/5.Group ParticipantsOpen to all adults ages 18 and up who are interested in learning about mindfulness and practicing in a group setting.Group size will be 10-12 people.Group work will consist of instruction, practice activities, discussion, and homework. Participants are encouraged to participate in all aspects of the group process in order to experience the benefit of mindfulness based stress reduction.No prior experience in mindfulness or meditation is required. All homework assignments and materials will be provided to group participants.Dates and AttendanceMeeting dates are as follows: February 5, 12, 19, 26, March 5, 12.By registering for the group, you are committing to attend all six sessions. If you are unable to attend more than one session, you may be asked to wait for later offerings of this group.Cost and PaymentTotal cost for the group is $300. Payment is non-transferrable and non-refundable.Two sliding scale spots are available and will be based on household income. If you need sliding scale, please make sure to indicate your need on the form below.After completing this form, one of the facilitators will reach out to ensure that this group is a good fit for your needs. If it is determined that this group would be a good fit for you, you will be required to pay a $100 deposit to hold your spot in the group. The remaining $200 of the group fee will be due by the first session on February 5th.If we do not have enough participants to run this group by January 29th, we will refund your deposit.LocationGroup will be held at Your Next Chapter Counseling's office in Asheville at 440 Montford Ave. Our group room is located on the third floor and is only accessible by stairs. Future offerings of this group may include virtual options to accommodate those who cannot make it to our office.Group FacilitatorsThis group will be co-facilitated by Audrey Philbrick, LCHMC, LCAS, and Emmi Lohrentz, LCSW.If you have any questions please contact:Audrey audrey@yournextchaptercounseling.comEmmi emmi@yournextchaptercounseling.com
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the best way to follow up with you
Call
Text
Email
Have you practiced mindfulness or meditation, and/or taken mindfulness classes before?
Yes
No
Please mark down any of the following that you are currently experiencing or have experienced in the last two weeks:
Feeling on edge or tense
Difficulty controlling worry
Difficulty concentrating
Frequent crying
Feeling sad, empty, or down
Frequent negative self-talk
Low self-esteem
Social withdrawal
Becoming annoyed or easily irritable
Trouble relaxing
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Thoughts that you would be better off dead, or hurting yourself
None of the above
Other
What is your comfort level with participating in group work?
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
Are you currently seeing an individual therapist?
Yes
No
No, and I would like to be connected with a therapist
This group will take place in person, at our office in the Montford neighborhood. Our group room is located on the third floor, which is only accessible by stairs. Would you be able to use the stairs to access this room?
Yes, I am able to use the stairs to access the third floor
No, I am unable to use stairs to access this room
The total cost of the groups for six weeks is $300. We have two sliding scale spots available based on household income. Would you need a sliding scale spot in order to participate in this group?
Yes, I need to pay on sliding scale.
No, I am able to pay $300 for the six week session.
What are your goals in joining this group?
Do you have any questions for us?
Submit
Should be Empty: