Anxiety & OCD Group Interest Form
Anxiety and OCD can sometimes take control of your life. In this 8-week group, we will focus on learning skills and tools to take back control utilizing exposure and response prevention (ERP), cognitive behavioral therapy (CBT), and acceptance and commitment therapy (ACT) with the support of therapists, Audrey Janssen and Ligia Rodriguez. Please provide your information below to see how we can best serve you.
Client Name
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First Name
Last Name
Today's Date
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Year
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Date of Birth
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Month
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Day
Year
Date
Age
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Home Address
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Street Address
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This group will meet on Tuesdays from 5-6:00PM from March 31st-May 19th. Are you able to attend all group sessions during the 8 weeks?
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Yes
No
Please specify any dates that you are not able to attend:
How does your anxiety impact you on a day-to-day basis?
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What do you hope you will be able to do differently by the end of the 8 weeks?
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Have you had any thoughts about killing yourself or acted on these thoughts?
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Yes
No
If yes, please explain:
Thank you for filling out this interest form!
We will be in contact soon regarding next steps! If you have any questions, feel free to call our office at 615-781-3000.
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