Parental Support Group Interest Form
This is a community oriented drop-in group that will provide a supportive and safe space for parents. You can share as much or as little as you feel comfortable. Listening with compassion is as valuable as sharing. Each week we focus on a theme, but you’re always welcome to bring what’s most present for you.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Have you participated in group therapy in the past?
Yes
No
What is your comfort level 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 personal therapist at Your Next Chapter
No, and I would like to receive referrals for therapists outside of Your Next Chapter
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 can access the third floor using stairs
No, I can not use the stairs to access the third floor
This group is donation based. The suggested donation is $15 per session. If this amount prohibits you from being able to participate, please choose from the options below:
I am able to donate $5 per session
I am able to donate $10 per session
I am able to donate $15 (or more) per session
I am not able to donate any money at this time
What are your goals in joining this group?
Do you have any questions for the facilitator of this group?
Submit
Should be Empty: