Chronic and Serious Illness Support Group
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!
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Phone Number
*
Format: (000) 000-0000.
Are you currently a patient at South Shore Counseling?
*
Please Select
Yes
No
If yes, who is your therapist?
The group will meet Wednesday afternoons in Wantagh on an ongoing basis. The start date and exact time are pending. Does this work for you?
*
Please Select
Yes
No
Insurance information, including name and policy number
*
What interests you about joining this group? Check as many as apply to you.
Connection with others
Emotional support
Coping with life transitions
Grief and loss
Health challenges
Loneliness
What diagnosis do you have? How long have you had this diagnosis for?
Describe the impact of the diagnos(es) on your life, in the past and present.
How would you describe your current emotional well-being?
*
Please Select
Very Good
Good
Fair
Poor
Have you ever participated in a support group before?
*
Please Select
Yes
No
Do you have any accessibility or mobility needs we should be aware of?
*
Please Select
Yes
No
If yes, please describe:
What goals do you have for joining this group? Is there anything else you would like us to know?
Submit
Should be Empty: